Basic Information
| Provider Information | |||||||||
| NPI: | 1235720194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LO | ||||||||
| FirstName: | CHEENOU | ||||||||
| MiddleName: | |||||||||
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| Credential: | CBT | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3230 COULTER CT | ||||||||
| Address2: | |||||||||
| City: | ANTELOPE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958434937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287818819 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3336 BRADSHAW RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166321330 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2021 | ||||||||
| LastUpdateDate: | 07/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 06/02/2021 | ||||||||
| NPIReactivationDate: | 07/09/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CB61077541 | WA | Y |
No ID Information.