MEDICARE: DR. THONGXAY SOUTHISENE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	C04-00296-J-094813	NV

General Provider Information

NPI Number	:	1518189737
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THONGXAY SOUTHISENE D.C.

Provider Business Mailing Address
First Line	:	6844 PHILIPPE ALLEN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89110-5240
Country	:	US
Telephone Number	:	702-339-4537
Fax Number	:

Provider Business Practice Location Address
First Line	:	1928 E SAHARA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-3843
Country	:	US
Telephone Number	:	702-457-4727
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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