Healthcare Provider Details

I. General information

NPI: 1851466650
Provider Name (Legal Business Name): KEN THOMAS VONGSAVATH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 N MAIN ST
FT STOCKTON TX
79735
US

IV. Provider business mailing address

313 E STOCKTON
ALPINE TX
79830
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-0700
  • Fax: 432-336-0704
Mailing address:
  • Phone: 432-837-9188
  • Fax: 432-837-9188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA00172
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: