Provider Demographics
NPI:1457082026
Name:THOMPSON, LILLIE ANGELINE
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:ANGELINE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1283 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1973
Mailing Address - Country:US
Mailing Address - Phone:803-905-5525
Mailing Address - Fax:803-905-5527
Practice Address - Street 1:1283 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1973
Practice Address - Country:US
Practice Address - Phone:803-905-5525
Practice Address - Fax:803-905-5527
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician