Healthcare Provider Details

I. General information

NPI: 1417942889
Provider Name (Legal Business Name): ADAM J THOMPSON PHD, ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 S WASHINGTON ST RECREATION & WELLNESS CENTER
MARION IN
46953-4974
US

IV. Provider business mailing address

4201 S WASHINGTON ST RECREATION & WELLNESS CENTER
MARION IN
46953-4974
US

V. Phone/Fax

Practice location:
  • Phone: 765-677-2335
  • Fax: 765-677-2328
Mailing address:
  • Phone: 765-677-2335
  • Fax: 765-677-2328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000570A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: