Provider Demographics
NPI:1992276166
Name:THOMPSON, CHARLES WESLEY
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WESLEY
Last Name:THOMPSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 GALLIA ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-4139
Mailing Address - Country:US
Mailing Address - Phone:740-935-1644
Mailing Address - Fax:
Practice Address - Street 1:902 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4139
Practice Address - Country:US
Practice Address - Phone:740-529-2125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty