=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831678127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THUNDERCLOUD OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/08/2018
-----------------------------------------------------
Last Update Date | 08/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4515 N 16TH ST STE 112
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-200-9803
-----------------------------------------------------
Fax | 602-200-9804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4515 N 16TH ST STE 112
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85016-5362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-200-9803
-----------------------------------------------------
Fax | 602-200-9804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER/ LICENSED OPTICIAN
-----------------------------------------------------
Name | MR. CHARLES FIELDER
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 602-200-9803
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1305E
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------