Provider Demographics
NPI:1255745964
Name:THOMPSON, LARA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
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 1:548 HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:RULEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38771-9729
Mailing Address - Country:US
Mailing Address - Phone:662-649-6174
Mailing Address - Fax:662-649-6174
Practice Address - Street 1:548 HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:RULEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38771-9729
Practice Address - Country:US
Practice Address - Phone:662-649-6174
Practice Address - Fax:662-649-6174
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver