Provider Demographics
NPI:1245012715
Name:SIVILAY, PHOUVIENG
Entity type:Individual
Prefix:
First Name:PHOUVIENG
Middle Name:
Last Name:SIVILAY
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 1:10428 SHELTER GRV
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4855
Mailing Address - Country:US
Mailing Address - Phone:612-508-8743
Mailing Address - Fax:
Practice Address - Street 1:10452 SPYGLASS DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55347-4656
Practice Address - Country:US
Practice Address - Phone:612-508-8743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39902310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility