1457760795 NPI number — MRS. CANDICE JEAN THOMPSON ASSOCIATES DIPLOMA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457760795 NPI number — MRS. CANDICE JEAN THOMPSON ASSOCIATES DIPLOMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
CANDICE
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ASSOCIATES DIPLOMA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCALUM
Provider Other First Name:
CANDICE
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457760795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
98 GEORGIA AVE BLDG 356
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STATESBORO
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30458-4960
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-478-3937
Provider Business Mailing Address Fax Number:
912-478-2537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
98 GEORGIA AVE BLDG 356
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATESBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30458-4960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-478-3937
Provider Business Practice Location Address Fax Number:
912-478-2537
Provider Enumeration Date:
08/12/2014

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: 156FX1800X , with the licence number:  LDO002461 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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