MEDICARE: DESIREE THOMAS

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	2255A2300X	Athletic Trainer	36002109A	IN
2	2255A2300X	Athletic Trainer	AT.004133	OH

General Provider Information

NPI Number	:	1902274764
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESIREE THOMAS

Provider Business Mailing Address
First Line	:	2212 PARKDALE DR
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1642
Country	:	US
Telephone Number	:	812-243-3913
Fax Number	:

Provider Business Practice Location Address
First Line	:	2021 CHESTER BLVD
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1235
Country	:	US
Telephone Number	:	765-983-3092
Fax Number	:

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

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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Directions to “ DESIREE THOMAS ” Practice Location

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