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General NPI Number Information
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NPI Number | 1184293862
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Entity Type | Organization
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Legal Business Name | THR PEDIATRICS & WELLNESS CENTER
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Dates
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Enumeration Date | 06/17/2021
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Last Update Date | 11/03/2021
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Provider Practice Location Address
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Address Line | 7098 DISTRIBUTION DR STE A
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City | LOUISVILLE
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State | KY
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Zip | 40258-2879
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Country | US
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Telephone | 502-749-8019
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Fax | 833-755-1833
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Provider Business Mailing Address
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Address Line | 9905 BROOKS BEND RD
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City | LOUISVILLE
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State | KY
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Zip | 40258-4638
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Country | US
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Telephone | 502-749-8019
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Fax | 833-755-1833
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Authorized Official
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Title or Position | PEDIATRIC PHYSICIAN ASSISTANT
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Name | DR. TYESHIA CHLOTIEL HALSELL RICHARDS
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Credential | DMSC, PA-C
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Telephone | 502-500-8955
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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