Active NPI
Kevin Khamvongsa
- Community/Behavioral Health Agency
- Crystal Lake, IL
National Provider Identifier
1467907170
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Behavioral Health Agency
- License
- S4S8C5H5
- Practice address
- 145 S Virginia St
Crystal Lake, IL 60014-7226 - Phone
- (815) 444-9999
- NPI assigned
- Aug 23, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community/Behavioral Health Agency | 251S00000X | S4S8C5H5 | IL | Primary |
Addresses
Primary practice location
145 S Virginia St
Crystal Lake, IL 60014-7226
Mailing address
145 S Virginia St
Crystal Lake, IL 60014-7226
Phone (815) 444-9999
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| S4S8C5H5 | IL | MD | Community/Behavioral Health Agency |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1471910400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1471910400000",
"number": "1467907170",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "145 S VIRGINIA ST",
"city": "CRYSTAL LAKE",
"state": "IL",
"postal_code": "600147226",
"telephone_number": "815-444-9999"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "145 S VIRGINIA ST",
"city": "CRYSTAL LAKE",
"state": "IL",
"postal_code": "600147226",
"telephone_number": "815-444-9999"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KHAMVONGSA",
"first_name": "KEVIN",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-08-23",
"last_updated": "2016-08-23",
"status": "A"
},
"taxonomies": [
{
"code": "251S00000X",
"taxonomy_group": "",
"desc": "Community/Behavioral Health",
"state": "IL",
"license": "S4S8C5H5",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Crystal Lake, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.