Provider Demographics
NPI:1407961048
Name:THOMPSON OUTPATIENT CLINIC, LLC
Entity Type:Organization
Organization Name:THOMPSON OUTPATIENT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:409-296-2910
Mailing Address - Street 1:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665-0714
Mailing Address - Country:US
Mailing Address - Phone:409-296-2910
Mailing Address - Fax:409-296-3003
Practice Address - Street 1:304 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7829
Practice Address - Country:US
Practice Address - Phone:409-296-2910
Practice Address - Fax:409-296-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171711803Medicaid
TX171711802Medicaid
TX0038MQOtherBCBS GROUP NUMBER
TXDC8996OtherMEDICARE RRW GROUP NUMBER
TX171711803Medicaid