Provider Demographics
NPI:1871195321
Name:THUNDER CITY EYE CARE LLC
Entity Type:Organization
Organization Name:THUNDER CITY EYE CARE LLC
Other - Org Name:THUNDER CITY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-832-5117
Mailing Address - Street 1:13200 N WESTERN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-1434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13200 N WESTERN AVE STE A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-1434
Practice Address - Country:US
Practice Address - Phone:405-024-5306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
J8987OtherMES VISION