Provider Demographics
NPI:1306368907
Name:OWENS, TELLY LESHAN
Entity Type:Individual
Prefix:
First Name:TELLY
Middle Name:LESHAN
Last Name:OWENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 BATHGATE RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23234-3581
Mailing Address - Country:US
Mailing Address - Phone:804-549-9115
Mailing Address - Fax:
Practice Address - Street 1:1405 WESTOVER HILLS BLVD STE 1A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-3153
Practice Address - Country:US
Practice Address - Phone:804-424-3260
Practice Address - Fax:804-424-3261
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA752156246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA81-4060372Medicaid