MEDICARE: THEDA EDWARDS-LABOME OWNER/BILLER/CODER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	0000000000	TX

General Provider Information

NPI Number	:	1144950585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THEDA EDWARDS-LABOME OWNER/BILLER/CODER

Provider Business Mailing Address
First Line	:	PO BOX 1404
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77459-1404
Country	:	US
Telephone Number	:	832-398-2707
Fax Number	:	832-770-4396

Provider Business Practice Location Address
First Line	:	15402 BLUERIDGE CT
Second Line	:
City	:	MISSOURI CITY
State	:	TX
Zip	:	77489-2606
Country	:	US
Telephone Number	:	832-398-2707
Fax Number	:	832-770-4396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2022
Last Update Date	:	06/16/2022

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