Provider Demographics
NPI:1205051463
Name:HUSTON, THOMAS LAVERNE
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:LAVERNE
Last Name:HUSTON
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 1:10 VIA FLORA CT
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-0995
Mailing Address - Country:US
Mailing Address - Phone:530-540-5626
Mailing Address - Fax:530-894-6115
Practice Address - Street 1:10 VIA FLORA CT
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-0995
Practice Address - Country:US
Practice Address - Phone:530-540-5626
Practice Address - Fax:530-894-6115
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101022332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA101022OtherDEPARTMENT OF HEALTH SERV
CASR KHB 99288461OtherSELLERS PERMIT
CA14105OtherBUSINESS LICENSE CERT
CA4526240002Medicare NSC