Provider Demographics
NPI:1679232730
Name:THEPSOUMPHONE, BOUNTHONG TOBY (DC, LMT, BS)
Entity type:Individual
Prefix:
First Name:BOUNTHONG
Middle Name:TOBY
Last Name:THEPSOUMPHONE
Suffix:
Gender:M
Credentials:DC, LMT, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2909 HAWTHORNE DR APT A
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-2971
Mailing Address - Country:US
Mailing Address - Phone:717-339-6676
Mailing Address - Fax:
Practice Address - Street 1:621 E KIMBERLY RD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1623
Practice Address - Country:US
Practice Address - Phone:563-359-1985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA115283111N00000X
IA094910225700000X
DEMT-0004508225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist