Healthcare Provider Details

I. General information

NPI: 1780147264
Provider Name (Legal Business Name): JOHN THOMPSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BAZEBERRY RD
CORDOVA TN
38018-7754
US

IV. Provider business mailing address

2745 LYNCHBURG ST
MEMPHIS TN
38134-4321
US

V. Phone/Fax

Practice location:
  • Phone: 901-758-0036
  • Fax:
Mailing address:
  • Phone: 901-691-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA0000005986
License Number StateTN

VII. Legacy identifiers

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

# 1
Identifier088118740
Identifier TypeOTHER
Identifier StateTN
Identifier IssuerDRIVING LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: