Provider Demographics
NPI:1053841478
Name:THACH, QUEEN LUCKY (OD)
Entity Type:Individual
Prefix:DR
First Name:QUEEN
Middle Name:LUCKY
Last Name:THACH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7419 CAMINITO CARLOTTA
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2907 JAMACHA RD STE A
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-4342
Practice Address - Country:US
Practice Address - Phone:619-660-0272
Practice Address - Fax:619-660-0310
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009101-01152W00000X
CAOPT33685-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist