Basic Information
| Provider Information | |||||||||
| NPI: | 1790149912 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOGAN RIVER EYE CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 S 100 W | ||||||||
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| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843215573 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1150 S 100 W | ||||||||
| Address2: | |||||||||
| City: | LOGAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843215573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4357543459 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | MILLER | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 4357543459 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 7532862-9934 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.