Provider Demographics
NPI:1972271245
Name:KANOKRAT CLINIC LLC
Entity Type:Organization
Organization Name:KANOKRAT CLINIC LLC
Other - Org Name:KANOKRAT CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:APRN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEERAPORN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-848-5393
Mailing Address - Street 1:211 CAROLINE ST OFC
Mailing Address - Street 2:
Mailing Address - City:CAPE CANAVERAL
Mailing Address - State:FL
Mailing Address - Zip Code:32920-2763
Mailing Address - Country:US
Mailing Address - Phone:321-417-1557
Mailing Address - Fax:321-204-7066
Practice Address - Street 1:211 CAROLINE ST OFC
Practice Address - Street 2:
Practice Address - City:CAPE CANAVERAL
Practice Address - State:FL
Practice Address - Zip Code:32920-2763
Practice Address - Country:US
Practice Address - Phone:321-613-2970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No251K00000XAgenciesPublic Health or Welfare
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherI DON'T HAVE ONE