Healthcare Provider Details

I. General information

NPI: 1114914405
Provider Name (Legal Business Name): CHANCHAI KAROUNA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 TOWN CENTER PKWY
SANTEE CA
92071
US

IV. Provider business mailing address

1583 VIA RONDA
SAN MARCOS CA
92069-3424
US

V. Phone/Fax

Practice location:
  • Phone: 619-596-0589
  • Fax: 619-596-0590
Mailing address:
  • Phone: 480-268-0937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 11160 TPA
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: