Basic Information
| Provider Information | |||||||||
| NPI: | 1538544093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THUNDER ROAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 40TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946092633 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 390 40TH ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946092633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106535040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2015 | ||||||||
| LastUpdateDate: | 07/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCFARLAN | ||||||||
| AuthorizedOfficialFirstName: | AVERY | ||||||||
| AuthorizedOfficialMiddleName: | ANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | RECOVERY COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 5106535040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 171M00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.