Healthcare Provider Details

I. General information

NPI: 1144932617
Provider Name (Legal Business Name): CHUN-BAXTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N NEW JERSEY ST APT 427
INDIANAPOLIS IN
46204-2889
US

IV. Provider business mailing address

8465 KEYSTONE XING STE 115
INDIANAPOLIS IN
46240-2453
US

V. Phone/Fax

Practice location:
  • Phone: 646-637-2915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State

VIII. Authorized Official

Name: WAN NA CHUN
Title or Position: REGISTERED DIETIAN
Credential:
Phone: 646-647-2915