Provider Demographics
NPI:1164677407
Name:THOMPSON, KIMBERLY J (LAC MSTOM)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:J
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:LAC MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6135 N BOOTH AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7364
Mailing Address - Country:US
Mailing Address - Phone:208-965-3777
Mailing Address - Fax:
Practice Address - Street 1:6135 N BOOTH AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7364
Practice Address - Country:US
Practice Address - Phone:208-373-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-244171100000X
ID173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No173C00000XOther Service ProvidersReflexologist