Healthcare Provider Details

I. General information

NPI: 1326474131
Provider Name (Legal Business Name): MR. JIM K INTHANONGSAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 VETERANS AVE
BATH NY
14810-0810
US

IV. Provider business mailing address

115 ORCHARD ST
HORSEHEADS NY
14845-2415
US

V. Phone/Fax

Practice location:
  • Phone: 607-664-4335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090203-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: