Provider Demographics
NPI:1093414302
Name:VANGKIM, MOUAFENG
Entity Type:Individual
Prefix:
First Name:MOUAFENG
Middle Name:
Last Name:VANGKIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:VANGKIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2121 DOXEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95131-2665
Mailing Address - Country:US
Mailing Address - Phone:951-208-5410
Mailing Address - Fax:
Practice Address - Street 1:2121 DOXEY DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95131-2665
Practice Address - Country:US
Practice Address - Phone:951-208-5410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician