1891234712 NPI number — MR. JOHN STEPHEN THACKER LAC, CMTPT

Table of content: MR. JOHN STEPHEN THACKER LAC, CMTPT (NPI 1891234712)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891234712 NPI number — MR. JOHN STEPHEN THACKER LAC, CMTPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THACKER
Provider First Name:
JOHN
Provider Middle Name:
STEPHEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LAC, CMTPT
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:
1891234712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
BLACKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24060-4863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-315-9763
Provider Business Mailing Address Fax Number:
540-605-7311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BLACKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24060-4863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-315-9763
Provider Business Practice Location Address Fax Number:
540-605-7311
Provider Enumeration Date:
02/13/2017

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: 171100000X , with the licence number:  0121000432 , 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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