Provider Demographics
NPI:1427706399
Name:LOUANGMILITH, SOUTSAKHONE
Entity type:Individual
Prefix:
First Name:SOUTSAKHONE
Middle Name:
Last Name:LOUANGMILITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7598 CARRIE RIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-1333
Mailing Address - Country:US
Mailing Address - Phone:619-536-9867
Mailing Address - Fax:
Practice Address - Street 1:220 S BARNWELL ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-4507
Practice Address - Country:US
Practice Address - Phone:619-246-0561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB9844883OtherDRIVER LICENSE