Healthcare Provider Details

I. General information

NPI: 1982928412
Provider Name (Legal Business Name): PRASEUTH SOUVANNAVONG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2010
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 S BRISTOL ST 218
SANTA ANA CA
92704-6209
US

IV. Provider business mailing address

2740 S BRISTOL ST 218
SANTA ANA CA
92704-6209
US

V. Phone/Fax

Practice location:
  • Phone: 714-754-8200
  • Fax: 714-754-8201
Mailing address:
  • Phone: 714-754-8200
  • Fax: 714-754-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: