Healthcare Provider Details

I. General information

NPI: 1407126469
Provider Name (Legal Business Name): TOMMY PHOUKHAOTHONG PANYANOUVONG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 PAYNE AVE
MODESTO CA
95351-4821
US

IV. Provider business mailing address

800 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-0662
  • Fax:
Mailing address:
  • Phone: 209-558-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberMPSSIUXREV
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberMPSS-IUXREV
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-IUXREV
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: