Provider Demographics
NPI:1114802196
Name:PITAKMOULCHON, PONGDEACH
Entity type:Individual
Prefix:
First Name:PONGDEACH
Middle Name:
Last Name:PITAKMOULCHON
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 1:22015 MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2233
Mailing Address - Country:US
Mailing Address - Phone:424-634-1789
Mailing Address - Fax:
Practice Address - Street 1:22015 MARIPOSA AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2233
Practice Address - Country:US
Practice Address - Phone:424-634-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-08
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist