Healthcare Provider Details

I. General information

NPI: 1871895599
Provider Name (Legal Business Name): KOSAL SUON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 PHOENIX AVE 2RD FLOOR
LOWELL MA
01852-4931
US

IV. Provider business mailing address

PO BOX 8025
LOWELL MA
01853-8025
US

V. Phone/Fax

Practice location:
  • Phone: 978-937-3087
  • Fax:
Mailing address:
  • Phone: 978-935-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: