MEDICARE: SOUK CHANTHABOURY IDMT

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	1710I1003X	Independent Duty Medical Technicians

General Provider Information

NPI Number	:	1750516977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOUK CHANTHABOURY IDMT

Provider Business Mailing Address
First Line	:	PSC 112 BOX 62
Second Line	:
City	:	APO
State	:	AE
Zip	:	09717-0001
Country	:	US
Telephone Number	:	0031413335950
Fax Number	:

Provider Business Practice Location Address
First Line	:	PSC 112
Second Line	:
City	:	APO
State	:	AE
Zip	:	09717-9998
Country	:	US
Telephone Number	:	0031413335950
Fax Number	:

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

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	05/04/2010

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Directions to “ SOUK CHANTHABOURY IDMT” Practice Location

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