| National Provider Identifier [NPI]: | 1194901173 |
| Last Name Of The Provider | THEPHAVONG |
| First Name Of The Provider | KHAMPHA |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | D.O |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2823 FRESNO ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | FRESNO |
| Zip Code Of The Provider | 937211324 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Osteopathic Manipulative Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 16 |
| Number Of Services | 384 |
| Number Of Medicare Beneficiaries | 72 |
| Total Submitted Charge Amount | 28804.96 |
| Total Medicare Allowed Amount | 22317.56 |
| Total Medicare Payment Amount | 14937.73 |
| Total Medicare Standardized Payment Amount | 14334.56 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 52 |
| Number Of Medicare Beneficiaries With Drug Services | 29 |
| Total Drug Submitted ChargeAmount | 1083 |
| Total Drug Medicare AllowedAmount | 430.35 |
| Total Drug Medicare PaymentAmount | 410.61 |
| Total Drug Medicare Standardized Payment Amount | 410.61 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 9 |
| Number Of Medical Services | 332 |
| Number Of Medicare Beneficiaries With Medical Services | 72 |
| Total Medical Submitted Charge Amount | 27721.96 |
| Total Medical Medicare Allowed Amount | 21887.21 |
| Total Medical Medicare Payment Amount | 14527.12 |
| Total Medical Medicare Standardized Payment Amount | 13923.95 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | 20 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 36 |
| Number Of Male Beneficiaries | 36 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 17 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 50 |
| Percent Of With Hyperlipidemia | 58 |
| Percent Of With Hypertension | 68 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1727 |