1710333638 NPI number — MR. SCOTT GOULD KINGPHAVONG LMT

Table of content: MR. SCOTT GOULD KINGPHAVONG LMT (NPI 1710333638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710333638 NPI number — MR. SCOTT GOULD KINGPHAVONG LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINGPHAVONG
Provider First Name:
SCOTT
Provider Middle Name:
GOULD
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOULD
Provider Other First Name:
SCOTT
Provider Other Middle Name:
ALLEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710333638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5936 ESSEX RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK FOREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60452-2824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
779-774-5493
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5936 ESSEX RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK FOREST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60452-2824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
779-774-5493
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  227.014953 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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