Provider Demographics
NPI:1568059830
Name:INTHAVONG, DARREN K
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:K
Last Name:INTHAVONG
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 1:7339 N 1ST ST STE 110
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2954
Mailing Address - Country:US
Mailing Address - Phone:916-729-3098
Mailing Address - Fax:
Practice Address - Street 1:1220 N FINE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1916
Practice Address - Country:US
Practice Address - Phone:155-932-6928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician