Basic Information
Provider Information | |||||||||
NPI: | 1114663507 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THOMPSON | ||||||||
FirstName: | KLACE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 142 ALFANI ST | ||||||||
Address2: |   | ||||||||
City: | DAVENPORT | ||||||||
State: | FL | ||||||||
PostalCode: | 338967025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3214445176 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 900 W MAGNOLIA ST | ||||||||
Address2: |   | ||||||||
City: | KISSIMMEE | ||||||||
State: | FL | ||||||||
PostalCode: | 347414117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8443316451 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2022 | ||||||||
LastUpdateDate: | 05/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-19-92415 | FL | Y |   |   |   |   |
No ID Information.