Provider Demographics
NPI:1447671078
Name:CHANTHINOUVONG, SOUPHA
Entity type:Individual
Prefix:
First Name:SOUPHA
Middle Name:
Last Name:CHANTHINOUVONG
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 1:2223 LOS FELIZ DR APT 102
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-3090
Mailing Address - Country:US
Mailing Address - Phone:734-394-9536
Mailing Address - Fax:
Practice Address - Street 1:812 AVIS DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-9649
Practice Address - Country:US
Practice Address - Phone:734-213-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-27
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other