Provider Demographics
NPI:1588240592
Name:CHHIN, SOPHEAKTRA
Entity Type:Individual
Prefix:
First Name:SOPHEAKTRA
Middle Name:
Last Name:CHHIN
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 1:1415 GOULD ST APT B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3082
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 GOULD ST APT B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3082
Practice Address - Country:US
Practice Address - Phone:909-534-8984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95136161163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency