MEDICARE: CORI THOMPSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL2637	FL

General Provider Information

NPI Number	:	1477968287
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CORI THOMPSON

Provider Business Mailing Address
First Line	:	1386 HARWICK ST SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32908-6249
Country	:	US
Telephone Number	:	321-652-6299
Fax Number	:

Provider Business Practice Location Address
First Line	:	1386 HARWICK ST SW
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32908-6249
Country	:	US
Telephone Number	:	321-652-6299
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2014
Last Update Date	:	07/01/2014

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