Provider Demographics
NPI:1588336879
Name:THOMPSON, SANDRA (CLP-202351-LAB)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:CLP-202351-LAB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6161 POLARIS DR
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-3476
Mailing Address - Country:US
Mailing Address - Phone:318-282-4757
Mailing Address - Fax:
Practice Address - Street 1:6161 POLARIS DR
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3476
Practice Address - Country:US
Practice Address - Phone:318-282-4757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LACLP-202351-LAB247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA87-2920548Medicaid