Provider Demographics
NPI:1891403002
Name:HUN, PUTHEAVY
Entity Type:Individual
Prefix:
First Name:PUTHEAVY
Middle Name:
Last Name:HUN
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 1:4591 ORANGE AVE UNIT 304
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2370
Mailing Address - Country:US
Mailing Address - Phone:562-781-6023
Mailing Address - Fax:
Practice Address - Street 1:3530 ATLANTIC AVE STE 210
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4569
Practice Address - Country:US
Practice Address - Phone:562-424-1886
Practice Address - Fax:562-424-2296
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program