Healthcare Provider Details

I. General information

NPI: 1710779558
Provider Name (Legal Business Name): SOU SAELEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 CHASE DR
RANCHO CORDOVA CA
95670-2078
US

IV. Provider business mailing address

1965 BIRKMONT DR
RANCHO CORDOVA CA
95742-6407
US

V. Phone/Fax

Practice location:
  • Phone: 916-294-2450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number95365788
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: