Provider Demographics
NPI:1568833457
Name:CHUONG, MIMI
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:CHUONG
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 1:3415 AMERICAN RIVER DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95864-5794
Mailing Address - Country:US
Mailing Address - Phone:916-737-7483
Mailing Address - Fax:
Practice Address - Street 1:2308 X ST APT 4
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-2527
Practice Address - Country:US
Practice Address - Phone:626-376-2695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-17
Last Update Date:2015-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator