Healthcare Provider Details

I. General information

NPI: 1710460704
Provider Name (Legal Business Name): BRIGHT LIGHT PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 09/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 E SAMPLE RD STE 103
POMPANO BEACH FL
33064-4443
US

IV. Provider business mailing address

PO BOX 668034
POMPANO BEACH FL
33066-8034
US

V. Phone/Fax

Practice location:
  • Phone: 612-643-0092
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: THESALEE N RANDON
Title or Position: OWNER
Credential: MD
Phone: 612-643-0092