Healthcare Provider Details

I. General information

NPI: 1306368907
Provider Name (Legal Business Name): TELLY LESHAN OWENS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 WESTOVER HILLS BLVD STE 1A
RICHMOND VA
23225-3153
US

IV. Provider business mailing address

4331 BATHGATE RD
RICHMOND VA
23234-3581
US

V. Phone/Fax

Practice location:
  • Phone: 804-424-3260
  • Fax: 804-424-3261
Mailing address:
  • Phone: 804-549-9115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number752156
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: