Basic Information
Provider Information | |||||||||
NPI: | 1992722888 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL UTAH EYE ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EXCEL EYE CENTER | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1735 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846041010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013741818 | ||||||||
FaxNumber: | 8013792959 | ||||||||
Practice Location | |||||||||
Address1: | 1735 N STATE ST | ||||||||
Address2: |   | ||||||||
City: | PROVO | ||||||||
State: | UT | ||||||||
PostalCode: | 846041010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8013741818 | ||||||||
FaxNumber: | 8013792959 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/16/2006 | ||||||||
LastUpdateDate: | 08/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLAKE | ||||||||
AuthorizedOfficialFirstName: | DALE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8013741818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
ID Information
ID | Type | State | Issuer | Description | CB6367 | 01 | UT | RAIL ROAD MEDICARE | OTHER |