MEDICARE: WANWALEE CHAROENCHOTE O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	593	NV

General Provider Information

NPI Number	:	1104072206
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANWALEE CHAROENCHOTE O.D.

Provider Business Mailing Address
First Line	:	5820 PROSPECTOR TRL
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-2052
Country	:	US
Telephone Number	:	702-501-7613
Fax Number	:

Provider Business Practice Location Address
First Line	:	4000 MEADOWS LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-3108
Country	:	US
Telephone Number	:	702-259-4287
Fax Number	:	702-878-8445

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2008
Last Update Date	:	04/18/2016

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