Provider Demographics
NPI:1649406398
Name:INTHANAM, VILAIVANH
Entity Type:Individual
Prefix:MISS
First Name:VILAIVANH
Middle Name:
Last Name:INTHANAM
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 1:19841 SW 117TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-4430
Mailing Address - Country:US
Mailing Address - Phone:786-205-0489
Mailing Address - Fax:
Practice Address - Street 1:147 ALHAMBRA CIR STE 140
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4529
Practice Address - Country:US
Practice Address - Phone:786-299-5290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist