Provider Demographics
NPI:1518624048
Name:WARDCHAODEE, PANUPONG
Entity Type:Individual
Prefix:
First Name:PANUPONG
Middle Name:
Last Name:WARDCHAODEE
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 1:1209 W SHERWIN AVE APT 703
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2254
Mailing Address - Country:US
Mailing Address - Phone:636-649-4562
Mailing Address - Fax:
Practice Address - Street 1:1209 W SHERWIN AVE APT 703
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-2254
Practice Address - Country:US
Practice Address - Phone:636-649-4562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227021294225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist