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Individual

KEVIN KHAMVONGSA

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man

Contact information

Practice address
145 S VIRGINIA ST, CRYSTAL LAKE, IL 60014-7226
(815) 444-9999
Mailing address
145 S VIRGINIA ST, CRYSTAL LAKE, IL 60014-7226
(815) 444-9999

Taxonomy

Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
S4S8C5H5
IL

Other

Enumeration date
08/23/2016
Last updated
08/23/2016
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