Healthcare Provider Details

I. General information

NPI: 1508293390
Provider Name (Legal Business Name): ROGER THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 10/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S 18TH ST
PARSONS KS
67357-3365
US

IV. Provider business mailing address

PO BOX 721
PARSONS KS
67357-0721
US

V. Phone/Fax

Practice location:
  • Phone: 620-421-2014
  • Fax: 620-421-2941
Mailing address:
  • Phone: 620-421-2014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number200392920A
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number200392920A
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200392920A
Identifier TypeMEDICAID
Identifier StateKS
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: