Provider Demographics
NPI:1164014478
Name:VANG, KONG N/A
Entity Type:Individual
Prefix:
First Name:KONG
Middle Name:N/A
Last Name:VANG
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 1:8049 MORGAN HILL WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-6348
Mailing Address - Country:US
Mailing Address - Phone:916-385-8090
Mailing Address - Fax:
Practice Address - Street 1:7240 E SOUTHGATE DR STE G
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2627
Practice Address - Country:US
Practice Address - Phone:916-391-4293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11385101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)