Healthcare Provider Details

I. General information

NPI: 1164888780
Provider Name (Legal Business Name): THADDEUS RICE FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S CHEVY CHASE DR SUITE 103
GLENDALE CA
91205-4431
US

IV. Provider business mailing address

10280 KURT ST
SYLMAR CA
91342
US

V. Phone/Fax

Practice location:
  • Phone: 818-850-5667
  • Fax: 818-839-2303
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95003569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: