Provider Demographics
NPI:1942822390
Name:PHOPROM, ELTON M
Entity type:Individual
Prefix:
First Name:ELTON
Middle Name:M
Last Name:PHOPROM
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 1:1520 MONTEBELLO DR
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3008
Mailing Address - Country:US
Mailing Address - Phone:707-863-2656
Mailing Address - Fax:
Practice Address - Street 1:1520 MONTEBELLO DR
Practice Address - Street 2:
Practice Address - City:SUISUN CITY
Practice Address - State:CA
Practice Address - Zip Code:94585-3008
Practice Address - Country:US
Practice Address - Phone:707-863-2656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor