Provider Demographics
NPI:1083722706
Name:THOMPSON, WADE C (DC)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:C
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5734 W 13400 S STE 200
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6953
Mailing Address - Country:US
Mailing Address - Phone:801-446-6220
Mailing Address - Fax:801-446-2166
Practice Address - Street 1:5734 W 13400 S STE 200
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84065-6953
Practice Address - Country:US
Practice Address - Phone:801-446-6220
Practice Address - Fax:801-446-2166
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4916781-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTV01499Medicare UPIN
UT005720301Medicare ID - Type UnspecifiedMEDICARE PART B #