Provider Demographics
NPI:1750516977
Name:CHANTHABOURY, SOUK (IDMT)
Entity type:Individual
Prefix:
First Name:SOUK
Middle Name:
Last Name:CHANTHABOURY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 112 BOX 62
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09717-0001
Mailing Address - Country:US
Mailing Address - Phone:003141-333-5950
Mailing Address - Fax:
Practice Address - Street 1:PSC 112
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09717-9998
Practice Address - Country:US
Practice Address - Phone:003141-333-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians