=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407961048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMPSON OUTPATIENT CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2006
-----------------------------------------------------
Last Update Date | 04/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 304 BROADWAY
-----------------------------------------------------
City | WINNIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77665-7829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-296-2910
-----------------------------------------------------
Fax | 409-296-3003
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 714
-----------------------------------------------------
City | WINNIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77665-0714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 409-296-2910
-----------------------------------------------------
Fax | 409-296-3003
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DANNY LEE THOMPSON
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 409-296-2910
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------