Healthcare Provider Details

I. General information

NPI: 1063539856
Provider Name (Legal Business Name): MICHAEL SHANE THOMPSON RAS, CDAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N 9TH ST
MODESTO CA
95350-5814
US

IV. Provider business mailing address

12309 HORSESHOE RD
OAKDALE CA
95361-9517
US

V. Phone/Fax

Practice location:
  • Phone: 209-541-2121
  • Fax:
Mailing address:
  • Phone: 209-847-5480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: