=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891819793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICA THORMAHLEN OPTICAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 E STATE ST
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92373-4754
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-692-1323
-----------------------------------------------------
Fax | 866-258-0370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2230 LAKE PARK DR SPC 186
-----------------------------------------------------
City | SAN JACINTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92583-7586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-692-1323
-----------------------------------------------------
Fax | 866-258-0370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | D1071
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------