Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 038-004727 | IL |
Y | 111NS0005X | Chiropractic Sports Physician | 038.004727 | IL |
NPI | 1205804499 |
---|---|
Provider Name | Dr. Terry Dean Thompson |
First Address | Palestine, IL 62451-1265 |
Second Address | Palestine, IL 62451-1265 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/03/2006 |
Last Update Date | 10/01/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
038004727 | (05) | IL |
371140723 | FEIN (01) | IL |
T38110 | (02) | IL |