Provider Demographics
NPI:1184293862
Name:THR PEDIATRICS & WELLNESS CENTER
Entity type:Organization
Organization Name:THR PEDIATRICS & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PHYSICIAN ASSISTANT
Authorized Official - Prefix:DR
Authorized Official - First Name:TYESHIA
Authorized Official - Middle Name:CHLOTIEL
Authorized Official - Last Name:HALSELL RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DMSC, PA-C
Authorized Official - Phone:502-500-8955
Mailing Address - Street 1:9905 BROOKS BEND RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-4638
Mailing Address - Country:US
Mailing Address - Phone:502-749-8019
Mailing Address - Fax:833-755-1833
Practice Address - Street 1:7098 DISTRIBUTION DR STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-2879
Practice Address - Country:US
Practice Address - Phone:502-749-8019
Practice Address - Fax:833-755-1833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-17
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100773670Medicaid