MEDICARE: SHAEDERRICA THEUS

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	376K00000X	Nurse's Aide		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	081112616	OTHER	TX	DBA

General Provider Information

NPI Number	:	1053814053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAEDERRICA THEUS

Provider Business Mailing Address
First Line	:	5311 WENDEL DR
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76133-4813
Country	:	US
Telephone Number	:	318-762-1281
Fax Number	:

Provider Business Practice Location Address
First Line	:	8640 COVE MEADOW LN
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76123-2330
Country	:	US
Telephone Number	:	318-762-1281
Fax Number	:

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

Provider Enumeration Date	:	03/15/2018
Last Update Date	:	03/15/2018

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Directions to “ SHAEDERRICA THEUS ” Practice Location

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