Provider First Line Business Practice Location Address:
228 ST 112
Provider Second Line Business Practice Location Address:
CHBAR OMPOV
Provider Business Practice Location Address City Name:
PHNOM PENH
Provider Business Practice Location Address State Name:
PHNOM PENH
Provider Business Practice Location Address Postal Code:
00000
Provider Business Practice Location Address Country Code:
KH
Provider Business Practice Location Address Telephone Number:
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2026