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General NPI Number Information
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NPI Number | 1720947807
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Entity Type | Individual
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Provider Name | SOUSITA BANGON EMANIVONG
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Gender | Female
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Dates
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Enumeration Date | 01/15/2026
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Last Update Date | 01/15/2026
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Provider Practice Location Address
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Address Line | 547 W MAIN ST
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City | MERCED
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State | CA
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Zip | 95340-4715
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Country | US
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Telephone | 209-384-1205
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Fax | 209-318-1380
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Provider Business Mailing Address
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Address Line | 547 W MAIN ST
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City | MERCED
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State | CA
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Zip | 95340-4715
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Country | US
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Telephone | 209-384-1205
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Fax | 209-318-1380
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State | CA
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