Provider Demographics
NPI:1346829751
Name:CHANTHAVONGNASAENG, BOUAKHAM
Entity Type:Individual
Prefix:
First Name:BOUAKHAM
Middle Name:
Last Name:CHANTHAVONGNASAENG
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 1:103 ROYAL PARK DR APT 4C
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-5832
Mailing Address - Country:US
Mailing Address - Phone:352-222-3730
Mailing Address - Fax:
Practice Address - Street 1:401 E SAMPLE RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-4441
Practice Address - Country:US
Practice Address - Phone:954-941-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-04
Last Update Date:2021-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25966225200000X
225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant