Provider Demographics
NPI:1457760795
Name:THOMPSON, CANDICE JEAN (ASSOCIATES DIPLOMA)
Entity Type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:JEAN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:ASSOCIATES DIPLOMA
Other - Prefix:
Other - First Name:CANDICE
Other - Middle Name:JEAN
Other - Last Name:MCALUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:98 GEORGIA AVE BLDG 356
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4960
Mailing Address - Country:US
Mailing Address - Phone:912-478-3937
Mailing Address - Fax:912-478-2537
Practice Address - Street 1:98 GEORGIA AVE BLDG 356
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4960
Practice Address - Country:US
Practice Address - Phone:912-478-3937
Practice Address - Fax:912-478-2537
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002461156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician