1770961856 NPI number — MR. LLEWELLYN THOMPSON III PTA

Table of content: MR. LLEWELLYN THOMPSON III PTA (NPI 1770961856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770961856 NPI number — MR. LLEWELLYN THOMPSON III PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THOMPSON
Provider First Name:
LLEWELLYN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
PTA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
TOM
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770961856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
717 GRAND VIEW AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN FRANCISCO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94114-3509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-579-3081
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
395 OYSTER POINT BLVD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
SOUTH SAN FRANCISCO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94080-1928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-758-4700
Provider Business Practice Location Address Fax Number:
866-758-4711
Provider Enumeration Date:
05/11/2015

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: 225200000X , with the licence number:  9680 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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