Provider Demographics
NPI:1508670480
Name:OU, CHANRITH
Entity type:Individual
Prefix:
First Name:CHANRITH
Middle Name:
Last Name:OU
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 1:4031 MADDIE CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-3767
Mailing Address - Country:US
Mailing Address - Phone:209-566-3300
Mailing Address - Fax:
Practice Address - Street 1:4422 N PERSHING AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6954
Practice Address - Country:US
Practice Address - Phone:209-953-8843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-03
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker