Provider Demographics
NPI:1063044147
Name:SENETHAVISUOK, SAL
Entity Type:Individual
Prefix:
First Name:SAL
Middle Name:
Last Name:SENETHAVISUOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 ARUBA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-5116
Mailing Address - Country:US
Mailing Address - Phone:614-316-2777
Mailing Address - Fax:
Practice Address - Street 1:4235 ARUBA DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-5116
Practice Address - Country:US
Practice Address - Phone:614-316-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33021667171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor