1629541230 NPI number — CHRISTIAN DREW THOMPSON

Table of content: CHRISTIAN DREW THOMPSON (NPI 1629541230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629541230 NPI number — CHRISTIAN DREW THOMPSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
CHRISTIAN
Provider Middle Name:
DREW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629541230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3587 HEATHROW WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-4004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-858-8170
Provider Business Mailing Address Fax Number:
541-858-8167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1945 NE 205TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRVIEW
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97024-9622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-661-8050
Provider Business Practice Location Address Fax Number:
503-492-4651
Provider Enumeration Date:
01/07/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)