Provider Demographics
NPI:1861476079
Name:PIROMGRAIPAKD, MITREE MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MITREE
Middle Name:MICHAEL
Last Name:PIROMGRAIPAKD
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 1:275 W HOSPITALITY LN STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3238
Mailing Address - Country:US
Mailing Address - Phone:909-567-2221
Mailing Address - Fax:909-567-2267
Practice Address - Street 1:275 W HOSPITALITY LN STE 103
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3238
Practice Address - Country:US
Practice Address - Phone:909-567-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT28630225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT286300Medicare PIN