Basic Information
| Provider Information | |||||||||
| NPI: | 1861865404 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EKTHEERACHAISAKUL | ||||||||
| FirstName: | PHOOWANAI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | RDN, CDN, CNSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 CLARKSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453131 | ||||||||
| FaxNumber: | 7182454345 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 CLARKSON AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182453131 | ||||||||
| FaxNumber: | 7182454345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2015 | ||||||||
| LastUpdateDate: | 03/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 1101790 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.