Provider Demographics
NPI:1659174134
Name:KEOPHIMPHONE, BAGIENG (MD)
Entity type:Individual
Prefix:
First Name:BAGIENG
Middle Name:
Last Name:KEOPHIMPHONE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2697 OMAHA AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-8478
Mailing Address - Country:US
Mailing Address - Phone:559-765-1046
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST # 10
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2059
Practice Address - Country:US
Practice Address - Phone:424-306-8008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-31
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program