MEDICARE: PANUPONG WARDCHAODEE

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	225700000X	Massage Therapist	227021294	IL

General Provider Information

NPI Number	:	1518624048
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PANUPONG WARDCHAODEE

Provider Business Mailing Address
First Line	:	1209 W SHERWIN AVE APT 703
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-2254
Country	:	US
Telephone Number	:	636-649-4562
Fax Number	:

Provider Business Practice Location Address
First Line	:	1209 W SHERWIN AVE APT 703
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-2254
Country	:	US
Telephone Number	:	636-649-4562
Fax Number	:

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

Provider Enumeration Date	:	11/18/2021
Last Update Date	:	11/18/2021

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Directions to “ PANUPONG WARDCHAODEE ” Practice Location

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