Healthcare Provider Details

I. General information

NPI: 1336446921
Provider Name (Legal Business Name): MARTIN THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14281 AVENUE 328
VISALIA CA
93292-9329
US

IV. Provider business mailing address

14281 AVENUE 328
VISALIA CA
93292-9329
US

V. Phone/Fax

Practice location:
  • Phone: 559-967-1708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT35867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: