Basic Information
| Provider Information | |||||||||
| NPI: | 1760972483 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAEPHANH | ||||||||
| FirstName: | KOY | ||||||||
| MiddleName: | HIN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4540 HARLIN DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958269716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163647800 | ||||||||
| FaxNumber: | 9163619987 | ||||||||
| Practice Location | |||||||||
| Address1: | 4540 HARLIN DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958269716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163647800 | ||||||||
| FaxNumber: | 9163619987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2018 | ||||||||
| LastUpdateDate: | 05/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-55963 | CA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP |
No ID Information.