Healthcare Provider Details

I. General information

NPI: 1497764161
Provider Name (Legal Business Name): MR. DARYL B THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 VETERANS DR
HARRISBURG IL
62946-3320
US

IV. Provider business mailing address

2510 E SUNSET RD UNIT 5-260
LAS VEGAS NV
89120-3511
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-2452
  • Fax: 618-294-8413
Mailing address:
  • Phone: 702-798-0113
  • Fax: 866-291-5242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number2811
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: