Basic Information
| Provider Information | |||||||||
| NPI: | 1255535019 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GAEWJUNDEE | ||||||||
| FirstName: | SUDSVAT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 MUSEUM BLVD UNIT 405 | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600613169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792270179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MENA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719533026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793942617 | ||||||||
| FaxNumber: | 4792430107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 03/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 2532 | AR | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070007343 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.