Basic Information
| Provider Information | |||||||||
| NPI: | 1548210032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THATCH | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2698 GRAVOIS RD | ||||||||
| Address2: | |||||||||
| City: | HIGH RIDGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630492508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366771166 | ||||||||
| FaxNumber: | 6366771324 | ||||||||
| Practice Location | |||||||||
| Address1: | 2698 GRAVOIS RD | ||||||||
| Address2: | |||||||||
| City: | HIGH RIDGE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630492508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6366771166 | ||||||||
| FaxNumber: | 6366771324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 046-009535 | IL | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2003014792 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | P00040122 | 01 | IL | MEDICARE RAILROAD | OTHER | 0814870023 | 01 | IL | MEDICARE NSC NUMBER | OTHER | 087817 | 01 | HEALTH ALLIANCE | OTHER | 046009535 | 05 | IL | MEDICAID | IL9535 | 01 | EYEMED | OTHER | 0814870026 | 01 | IL | MEDICARE NSC NUMBER | OTHER | 252039 | 01 | HARMONY HEALTH PLAN | OTHER | 0814870010 | 01 | IL | MEDICARE NSC NUMBER | OTHER |