Provider Demographics
NPI:1669717005
Name:THOMPSON, GARY R (DC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:R
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380878
Mailing Address - Street 2:
Mailing Address - City:MURDOCK
Mailing Address - State:FL
Mailing Address - Zip Code:33938-0878
Mailing Address - Country:US
Mailing Address - Phone:941-766-1882
Mailing Address - Fax:941-766-1256
Practice Address - Street 1:2101 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-2186
Practice Address - Country:US
Practice Address - Phone:941-766-1882
Practice Address - Fax:941-766-1256
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH5664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor