Provider Demographics
NPI:1780180208
Name:CHAIYARAT, WILAWAN NONE
Entity Type:Individual
Prefix:
First Name:WILAWAN
Middle Name:NONE
Last Name:CHAIYARAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 INWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-6302
Mailing Address - Country:US
Mailing Address - Phone:978-688-8228
Mailing Address - Fax:
Practice Address - Street 1:89 MORTON ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-2036
Practice Address - Country:US
Practice Address - Phone:978-475-0944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11956261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy