Healthcare Provider Details

I. General information

NPI: 1144070749
Provider Name (Legal Business Name): THE CAMBODIAN FAMILY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 E 4TH ST
SANTA ANA CA
92701-5148
US

IV. Provider business mailing address

1626 E 4TH ST
SANTA ANA CA
92701-5148
US

V. Phone/Fax

Practice location:
  • Phone: 714-571-1966
  • Fax:
Mailing address:
  • Phone: 714-571-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. VATTANA PEONG
Title or Position: EXECUTIVE DIRECTOR
Credential: MPH
Phone: 714-571-1966