Healthcare Provider Details

I. General information

NPI: 1508553900
Provider Name (Legal Business Name): BLAICHIA THAO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 11/04/2026
Certification Date: 11/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 E MONTCLAIR ST
SPRINGFIELD MO
65807-5068
US

IV. Provider business mailing address

11900 E 12 MILE RD STE 102
WARREN MI
48093-3487
US

V. Phone/Fax

Practice location:
  • Phone: 417-883-1881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2026030564
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: