Provider Demographics
NPI:1295865749
Name:PEL, CHANTRAVUTH K (LVN)
Entity Type:Individual
Prefix:MR
First Name:CHANTRAVUTH
Middle Name:K
Last Name:PEL
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-391-7948
Mailing Address - Fax:661-391-7978
Practice Address - Street 1:17695 INDUSTRIAL FARM RD
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-9520
Practice Address - Country:US
Practice Address - Phone:661-391-7948
Practice Address - Fax:661-391-7978
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 192537164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse