Provider Demographics
NPI:1861865404
Name:EKTHEERACHAISAKUL, PHOOWANAI (RDN, CDN, CNSC)
Entity Type:Individual
Prefix:MR
First Name:PHOOWANAI
Middle Name:
Last Name:EKTHEERACHAISAKUL
Suffix:
Gender:M
Credentials:RDN, CDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 CLARKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2054
Mailing Address - Country:US
Mailing Address - Phone:718-245-3131
Mailing Address - Fax:718-245-4345
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-3131
Practice Address - Fax:718-245-4345
Is Sole Proprietor?:No
Enumeration Date:2015-11-04
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1101790133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered