Provider Demographics
NPI:1114643319
Name:POOLPUONG, NEVIN
Entity type:Individual
Prefix:
First Name:NEVIN
Middle Name:
Last Name:POOLPUONG
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 1:15275 KENOAK DR
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3427
Mailing Address - Country:US
Mailing Address - Phone:626-254-3755
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:800-464-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TBDOtherTBD