Provider Demographics
NPI:1134810534
Name:ROMERO, PANNAWIT PAMUANGMOON (CAMTC #82109)
Entity type:Individual
Prefix:
First Name:PANNAWIT
Middle Name:PAMUANGMOON
Last Name:ROMERO
Suffix:
Gender:M
Credentials:CAMTC #82109
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14163 HUBBARD ST
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4713
Mailing Address - Country:US
Mailing Address - Phone:424-625-5944
Mailing Address - Fax:
Practice Address - Street 1:14163 HUBBARD ST
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4713
Practice Address - Country:US
Practice Address - Phone:424-625-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82109225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist