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General NPI Number Information
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NPI Number | 1710460704
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Entity Type | Organization
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Legal Business Name | BRIGHT LIGHT PEDIATRICS, PLLC
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Dates
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Enumeration Date | 09/14/2018
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Last Update Date | 09/14/2018
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Provider Practice Location Address
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Address Line | 601 E SAMPLE RD STE 103
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City | POMPANO BEACH
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State | FL
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Zip | 33064-4443
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Country | US
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Telephone | 612-643-0092
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 668034
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City | POMPANO BEACH
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State | FL
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Zip | 33066-8034
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | THESALEE N RANDON
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Credential | MD
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Telephone | 612-643-0092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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