Provider Demographics
NPI:1023884392
Name:BOUNYAVONG, TRINITY
Entity type:Individual
Prefix:
First Name:TRINITY
Middle Name:
Last Name:BOUNYAVONG
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 1:526 W TRIBELLA CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-3697
Mailing Address - Country:US
Mailing Address - Phone:208-949-7206
Mailing Address - Fax:
Practice Address - Street 1:6032 VILLAGE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-3129
Practice Address - Country:US
Practice Address - Phone:562-542-5471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician