1104082064 NPI number — SHANDON J. THOMPSON, D.C., P.C.

Table of content: (NPI 1104082064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104082064 NPI number — SHANDON J. THOMPSON, D.C., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHANDON J. THOMPSON, D.C., P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1104082064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
44121 HARRY BYRD HWY
Provider Second Line Business Mailing Address:
#120
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-5667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-777-1234
Provider Business Mailing Address Fax Number:
571-918-0760

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
44121 HARRY BYRD HWY
Provider Second Line Business Practice Location Address:
#120
Provider Business Practice Location Address City Name:
ASHBURN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20147-5667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-777-1234
Provider Business Practice Location Address Fax Number:
703-777-8277
Provider Enumeration Date:
07/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
THOMPSON
Authorized Official First Name:
SHANDON
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
703-777-1234

Provider Taxonomy Codes

  • Taxonomy code: 111NS0005X , with the licence number:  0104001181 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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