Provider Demographics
NPI:1275106635
Name:ARCHER, THOMAS (LMBT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:ARCHER
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9902 LEAF ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0011
Mailing Address - Country:US
Mailing Address - Phone:704-968-4633
Mailing Address - Fax:
Practice Address - Street 1:2300 RANDOLPH RD STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1586
Practice Address - Country:US
Practice Address - Phone:704-968-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC47-5081821OtherPRIVATE INSURANCE