Provider Demographics
NPI:1811423205
Name:LERTKITCHAROENPON, WIRAT (PT,DPT)
Entity Type:Individual
Prefix:
First Name:WIRAT
Middle Name:
Last Name:LERTKITCHAROENPON
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 FOROUGH CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6023
Mailing Address - Country:US
Mailing Address - Phone:386-562-5439
Mailing Address - Fax:386-760-8927
Practice Address - Street 1:1849 FOROUGH CIR
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6023
Practice Address - Country:US
Practice Address - Phone:386-562-5439
Practice Address - Fax:386-760-8927
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT11845225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist