Provider Demographics
NPI:1205108578
Name:TOKIJKLA, YUTTHANA (ATP)
Entity type:Individual
Prefix:MR
First Name:YUTTHANA
Middle Name:
Last Name:TOKIJKLA
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1972 GINKGO ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407-2365
Mailing Address - Country:US
Mailing Address - Phone:909-289-5874
Mailing Address - Fax:
Practice Address - Street 1:1972 GINKGO ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92407-2365
Practice Address - Country:US
Practice Address - Phone:909-289-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAATP4665225CA2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CA2500XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA941158OtherBUSINESS LICENSE
CASR EH 102-178362OtherSELLERS PERMIT