Healthcare Provider Details

I. General information

NPI: 1528373503
Provider Name (Legal Business Name): TERRY M THOMPSON C.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2010
Last Update Date: 08/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3672 MARATHON CIR SUITE 140
AUSTELL GA
30106-6821
US

IV. Provider business mailing address

PO BOX 24905
WINSTON SALEM NC
27114-4905
US

V. Phone/Fax

Practice location:
  • Phone: 678-738-7380
  • Fax: 678-738-7382
Mailing address:
  • Phone: 336-397-2165
  • Fax: 336-397-2167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number49
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: