MEDICARE: MS. LAURA M THOMPSON RD

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	133V00000X	Registered Dietitian	37001794A	IN
2	133V00000X	Registered Dietitian	KY-2043	KY
3	133V00000X	Registered Dietitian		IL

General Provider Information

NPI Number	:	1649456450
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURA M THOMPSON RD

Provider Business Mailing Address
First Line	:	5653 CALLE LAS COLINAS
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47712-2712
Country	:	US
Telephone Number	:	812-779-7005
Fax Number	:

Provider Business Practice Location Address
First Line	:	5653 CALLE LAS COLINAS
Second Line	:
City	:	EVANSVILLE
State	:	IN
Zip	:	47712-2712
Country	:	US
Telephone Number	:	812-779-7005
Fax Number	:

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

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	01/11/2008

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