Provider Demographics
NPI:1003179953
Name:THUNDERMIST, INC.
Entity Type:Organization
Organization Name:THUNDERMIST, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LLC
Authorized Official - Phone:888-898-4591
Mailing Address - Street 1:2108A SILVERNAIL RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-5526
Mailing Address - Country:US
Mailing Address - Phone:888-468-9981
Mailing Address - Fax:
Practice Address - Street 1:2108A SILVERNAIL RD
Practice Address - Street 2:SUITE 116
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-5526
Practice Address - Country:US
Practice Address - Phone:888-468-9981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health