MEDICARE: VIENGKHONE SAYADETH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	80264	CA

General Provider Information

NPI Number	:	1083306245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIENGKHONE SAYADETH

Provider Business Mailing Address
First Line	:	2393 E JORDAN AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93720-0270
Country	:	US
Telephone Number	:	559-577-0415
Fax Number	:

Provider Business Practice Location Address
First Line	:	5649 N PALM AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93704-1851
Country	:	US
Telephone Number	:	559-222-6262
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2023
Last Update Date	:	05/24/2023

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Directions to “ VIENGKHONE SAYADETH ” Practice Location

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