Provider Demographics
NPI:1831678127
Name:THUNDERCLOUD OPTICAL
Entity Type:Organization
Organization Name:THUNDERCLOUD OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER/ LICENSED OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDER
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:602-200-9803
Mailing Address - Street 1:4515 N 16TH ST STE 112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-5362
Mailing Address - Country:US
Mailing Address - Phone:602-200-9803
Mailing Address - Fax:602-200-9804
Practice Address - Street 1:4515 N 16TH ST STE 112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-5362
Practice Address - Country:US
Practice Address - Phone:602-200-9803
Practice Address - Fax:602-200-9804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1305E332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier