Provider Demographics
NPI:1871354555
Name:THOMPSON, MIRANDA (ABOC, NCLEC, FL LDO)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:ABOC, NCLEC, FL LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3508
Mailing Address - Country:US
Mailing Address - Phone:904-548-7841
Mailing Address - Fax:
Practice Address - Street 1:601 N LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1426
Practice Address - Country:US
Practice Address - Phone:906-786-2466
Practice Address - Fax:906-786-9174
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO7031156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician