Basic Information
| Provider Information | |||||||||
| NPI: | 1891882155 | ||||||||
| 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: | 1200 PROVO TOWNE CENTRE | ||||||||
| Address2: | 1060 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013732254 | ||||||||
| FaxNumber: | 8018525014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 09/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | ACKER | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8018862020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | UT | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1891882155 | 05 | UT | MEDICAID | 999000797009 | 05 | UT | MEDICAID |