Healthcare Provider Details

I. General information

NPI: 1346829751
Provider Name (Legal Business Name): BOUAKHAM CHANTHAVONGNASAENG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2021
Last Update Date: 04/04/2021
Certification Date: 04/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E SAMPLE RD
DEERFIELD BEACH FL
33064-4441
US

IV. Provider business mailing address

103 ROYAL PARK DR APT 4C
OAKLAND PARK FL
33309-5832
US

V. Phone/Fax

Practice location:
  • Phone: 954-941-4100
  • Fax:
Mailing address:
  • Phone: 352-222-3730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA25966
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: