Provider Demographics
NPI:1285821389
Name:DUANGTAVAN SOURIVONG
Entity Type:Organization
Organization Name:DUANGTAVAN SOURIVONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEARNS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:619-262-8000
Mailing Address - Street 1:4852 JARRETT CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-3598
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3940 HOME AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5952
Practice Address - Country:US
Practice Address - Phone:619-262-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone