Basic Information
| Provider Information | |||||||||
| NPI: | 1386174324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SRISATHAPAT | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | HEIM | ||||||||
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| Credential: | LAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18909 FLORWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905045631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492740344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10000 FLOWER ST | ||||||||
| Address2: | |||||||||
| City: | BELLFLOWER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907065413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628043449 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 17502 | CA | Y | Other Service Providers | Acupuncturist |
No ID Information.