Healthcare Provider Details

I. General information

NPI: 1619836525
Provider Name (Legal Business Name): CHRISTIAN KONG PHENG VANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9355 E STOCKTON BLVD STE 185
ELK GROVE CA
95624-9476
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 200
LAKE MARY FL
32746-5028
US

V. Phone/Fax

Practice location:
  • Phone: 915-270-1421
  • Fax:
Mailing address:
  • Phone: 866-610-0580
  • Fax: 866-611-1558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: