Provider Demographics
NPI:1891015681
Name:THONGLYVONG, RICKY
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:
Last Name:THONGLYVONG
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 1:803 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2322
Mailing Address - Country:US
Mailing Address - Phone:651-222-2787
Mailing Address - Fax:651-224-1057
Practice Address - Street 1:23 EMPIRE DR
Practice Address - Street 2:SUITE 123
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55103-1856
Practice Address - Country:US
Practice Address - Phone:651-222-2787
Practice Address - Fax:651-224-1057
Is Sole Proprietor?:No
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant