1508282385 NPI number — MR. CLARENCE ALLEY THOMPSON III M.F.C.C.

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 1508282385 NPI number — MR. CLARENCE ALLEY THOMPSON III M.F.C.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
CLARENCE
Provider Middle Name:
ALLEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
M.F.C.C.
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:
1508282385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 4TH AVE
Provider Second Line Business Mailing Address:
#203
Provider Business Mailing Address City Name:
VENICE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90291-8605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-396-1716
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 4TH AVE
Provider Second Line Business Practice Location Address:
#203
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90291-8605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-396-1716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2014

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: 101YM0800X , with the licence number:  MFC 28772 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MFC 28772 . This is a "COBRA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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