Healthcare Provider Details

I. General information

NPI: 1710926563
Provider Name (Legal Business Name): RANDALL EUGENE THOMPSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 COCHRANE CIR
FORT CARSON CO
80913-4603
US

IV. Provider business mailing address

PO BOX 157
FOUNTAIN CO
80817-0157
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7071
  • Fax:
Mailing address:
  • Phone: 719-964-4823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number125342
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: