Individual
KHAMPASONG HALEUDETH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
275 MYSTIC AVE STE C, MEDFORD, MA 02155-6301
(781) 874-9294
Mailing address
275 MYSTIC AVE STE C, MEDFORD, MA 02155-6301
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
25676
MA
Other
Enumeration date
09/20/2021
Last updated
09/20/2021
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