Provider Demographics
NPI:1881313492
Name:CHUANGSAMRONG, WANCHAI
Entity type:Individual
Prefix:
First Name:WANCHAI
Middle Name:
Last Name:CHUANGSAMRONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 PALOMAR CT
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4711
Mailing Address - Country:US
Mailing Address - Phone:415-490-6434
Mailing Address - Fax:
Practice Address - Street 1:315 PALOMAR CT
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-4711
Practice Address - Country:US
Practice Address - Phone:415-490-6434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288518164W00000X
CA89210225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse