Provider Demographics
NPI:1093092132
Name:THOMPSON, EZELL JR
Entity Type:Individual
Prefix:MR
First Name:EZELL
Middle Name:
Last Name:THOMPSON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2711 FOUR SEASONS BLVD
Mailing Address - Street 2:UNIT F
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-6078
Mailing Address - Country:US
Mailing Address - Phone:434-429-3077
Mailing Address - Fax:
Practice Address - Street 1:2711 FOUR SEASONS BLVD
Practice Address - Street 2:UNIT F
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-6078
Practice Address - Country:US
Practice Address - Phone:434-429-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC263585347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle