Provider Demographics
NPI:1942521661
Name:RATANAVONGSA, LATHAI
Entity Type:Individual
Prefix:
First Name:LATHAI
Middle Name:
Last Name:RATANAVONGSA
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 1:4901 CLAIR DEL AVE APT 1208
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-6194
Mailing Address - Country:US
Mailing Address - Phone:520-270-1918
Mailing Address - Fax:
Practice Address - Street 1:801 E CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3839
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner