Provider Demographics
NPI:1205804499
Name:THOMPSON, TERRY DEAN (DC, CCSP)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:DEAN
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:IL
Mailing Address - Zip Code:62451-1265
Mailing Address - Country:US
Mailing Address - Phone:618-586-5454
Mailing Address - Fax:618-586-9470
Practice Address - Street 1:117 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:IL
Practice Address - Zip Code:62451-1265
Practice Address - Country:US
Practice Address - Phone:618-586-5454
Practice Address - Fax:618-586-9470
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2009-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004727111N00000X
IL038.004727111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038004727Medicaid
IL371140723OtherFEIN
IL038004727Medicaid
ILT38110Medicare UPIN