Basic Information
Provider Information
NPI: 1043311582
EntityType: 2
ReplacementNPI:  
OrganizationName: STANDARD OPTICAL CO
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Mailing Information
Address1: 1901 W PARKWAY BLVD
Address2:  
City: SALT LAKE CITY
State: UT
PostalCode: 84119
CountryCode: US
TelephoneNumber: 8018862020
FaxNumber: 8019540054
Practice Location
Address1: 4878 HIGHLAND DR
Address2: CREEKSIDE PLAZA
City: HOLLADAY
State: UT
PostalCode: 841176007
CountryCode: US
TelephoneNumber: 8012728861
FaxNumber: 8012728867
Other Information
ProviderEnumerationDate: 09/26/2006
LastUpdateDate: 03/23/2021
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AuthorizedOfficialLastName: WOODS
AuthorizedOfficialFirstName: ALYSA
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AuthorizedOfficialTitleorPosition: OFFICE MANAGER
AuthorizedOfficialTelephone: 8018862020
IsSoleProprietor:  
IsOrganizationSubpart: N
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NPICertificationDate: 03/23/2021

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207W00000X UTN193200000X MULTI-SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOphthalmology 
152W00000X UTY193200000X MULTI-SPECIALTY GROUPEye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
99900079700905UT MEDICAID
26992901UTALTIUSOTHER
92055501UTDMBAOTHER
104331158205UT MEDICAID


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