Healthcare Provider Details

I. General information

NPI: 1083956668
Provider Name (Legal Business Name): NATHAN THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2013
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 LONE PINE RD
MEDFORD OR
97504-5637
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 541-772-1777
  • Fax:
Mailing address:
  • Phone: 541-672-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: