Provider Demographics
NPI:1861019804
Name:SAMPSON, THOMAS JACK
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JACK
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 BROADWAY ST S
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-3950
Mailing Address - Country:US
Mailing Address - Phone:715-308-3837
Mailing Address - Fax:
Practice Address - Street 1:2021 BROADWAY ST S
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-3950
Practice Address - Country:US
Practice Address - Phone:715-308-3837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1124661133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist