Healthcare Provider Details

I. General information

NPI: 1295963817
Provider Name (Legal Business Name): EDWIN EUGENE THOMPSON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21435 42ND AVE 3RD FLOOR
BAYSIDE NY
11361-2917
US

IV. Provider business mailing address

21435 42ND AVE 3RD FLOOR
BAYSIDE NY
11361-2917
US

V. Phone/Fax

Practice location:
  • Phone: 718-229-4868
  • Fax: 718-229-4993
Mailing address:
  • Phone: 718-229-4868
  • Fax: 718-229-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX011677
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: