Provider Demographics
NPI:1346782646
Name:PHETPHOMMASOUK, MAKHA
Entity Type:Individual
Prefix:
First Name:MAKHA
Middle Name:
Last Name:PHETPHOMMASOUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2196 WOLFBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-6188
Mailing Address - Country:US
Mailing Address - Phone:707-548-1875
Mailing Address - Fax:
Practice Address - Street 1:95 MONTGOMERY DR
Practice Address - Street 2:126
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6630
Practice Address - Country:US
Practice Address - Phone:707-861-0625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-17
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17021171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist