MEDICARE: THUNDERCLOUD OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	1305E	AZ

General Provider Information

NPI Number	:	1831678127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THUNDERCLOUD OPTICAL

Provider Business Mailing Address
First Line	:	4515 N 16TH ST STE 112
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5362
Country	:	US
Telephone Number	:	602-200-9803
Fax Number	:	602-200-9804

Provider Business Practice Location Address
First Line	:	4515 N 16TH ST STE 112
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-5362
Country	:	US
Telephone Number	:	602-200-9803
Fax Number	:	602-200-9804

Authorized Official
Title or Position	:	GENERAL MANAGER/ LICENSED OPTICIAN
Name	:	MR. CHARLES FIELDER
Credential	:	LDO
Telephone Number	:	602-200-9803

Provider Enumeration Date	:	08/08/2018
Last Update Date	:	08/08/2018

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Directions to “THUNDERCLOUD OPTICAL ” Practice Location

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