Healthcare Provider Details

I. General information

NPI: 1699106112
Provider Name (Legal Business Name): KOMKRIT KAEWCHAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8501 N MACARTHUR BLVD 0582 C/O CONSULTANT USA
IRVING TX
75063-4100
US

IV. Provider business mailing address

2668 N BELT LINE RD
IRVING TX
75062-5245
US

V. Phone/Fax

Practice location:
  • Phone: 469-442-7405
  • Fax:
Mailing address:
  • Phone: 972-513-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberL3804
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberL3804
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: