Provider Demographics
NPI:1104003763
Name:EVELYN LAVERN THOMPSON
Entity Type:Organization
Organization Name:EVELYN LAVERN THOMPSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:L.V.N
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-485-6847
Mailing Address - Street 1:12279 LASSELLE ST
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7705
Mailing Address - Country:US
Mailing Address - Phone:951-485-6847
Mailing Address - Fax:
Practice Address - Street 1:12279 LASSELLE ST
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92557-7705
Practice Address - Country:US
Practice Address - Phone:951-485-6847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN1298323140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric