Basic Information
| Provider Information | |||||||||
| NPI: | 1710327044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOUAVANGSOU | ||||||||
| FirstName: | PANGCHEE | ||||||||
| MiddleName: | MYER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5896 E CLUB VIEW DR | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937276211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5597905577 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 40 E MINARETS AVE | ||||||||
| Address2: | |||||||||
| City: | PINEDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936501239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594360482 | ||||||||
| FaxNumber: | 5594364650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2013 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.