Healthcare Provider Details

I. General information

NPI: 1902274764
Provider Name (Legal Business Name): DESIREE THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 CHESTER BLVD
RICHMOND IN
47374-1235
US

IV. Provider business mailing address

2212 PARKDALE DR
RICHMOND IN
47374-1642
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3092
  • Fax:
Mailing address:
  • Phone: 812-243-3913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36002109A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT.004133
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: