Provider Demographics
NPI:1598200222
Name:SOK, BUNRETH
Entity Type:Individual
Prefix:
First Name:BUNRETH
Middle Name:
Last Name:SOK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BUNRETH
Other - Middle Name:MAY
Other - Last Name:SOK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:121 LAS FLORES AVE APT C
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95354-1458
Mailing Address - Country:US
Mailing Address - Phone:916-459-8457
Mailing Address - Fax:
Practice Address - Street 1:1235 MCHENRY AVE STE A
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5370
Practice Address - Country:US
Practice Address - Phone:209-527-4597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)