Provider Demographics
NPI:1659111847
Name:INTHAVONGSAY, ZAKAI IVAN
Entity type:Individual
Prefix:
First Name:ZAKAI
Middle Name:IVAN
Last Name:INTHAVONGSAY
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 1:176 BIG HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:LIZEMORES
Mailing Address - State:WV
Mailing Address - Zip Code:25125-8126
Mailing Address - Country:US
Mailing Address - Phone:304-663-9182
Mailing Address - Fax:
Practice Address - Street 1:176 BIG HOLLOW RD
Practice Address - Street 2:
Practice Address - City:LIZEMORES
Practice Address - State:WV
Practice Address - Zip Code:25125-8126
Practice Address - Country:US
Practice Address - Phone:304-663-9182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant