Healthcare Provider Details

I. General information

NPI: 1164745287
Provider Name (Legal Business Name): MARILYN DENISE THOMPSON PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W CALIFORNIA AVE
VISTA CA
92083-3622
US

IV. Provider business mailing address

215 W CALIFORNIA AVE
VISTA CA
92083-3622
US

V. Phone/Fax

Practice location:
  • Phone: 760-724-0831
  • Fax: 760-631-0652
Mailing address:
  • Phone: 760-724-0831
  • Fax: 760-631-0652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT14860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: