Provider Demographics
NPI:1427860089
Name:TIV, CHANMOROKOTH
Entity type:Individual
Prefix:
First Name:CHANMOROKOTH
Middle Name:
Last Name:TIV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11039 ZEOLITE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-1639
Mailing Address - Country:US
Mailing Address - Phone:916-335-2207
Mailing Address - Fax:
Practice Address - Street 1:10345 PROFESSIONAL CIR STE 125
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-3100
Practice Address - Country:US
Practice Address - Phone:775-348-7300
Practice Address - Fax:855-253-3789
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV884707164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse