MEDICARE: FAMILY VISION CARE OF OGDEN PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	111347-9934	UT

General Provider Information

NPI Number	:	1184974883
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY VISION CARE OF OGDEN PC

Provider Business Mailing Address
First Line	:	1055 N WASHINGTON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3605
Country	:	US
Telephone Number	:	801-394-5709
Fax Number	:	801-394-5710

Provider Business Practice Location Address
First Line	:	1055 N WASHINGTON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3605
Country	:	US
Telephone Number	:	801-394-5709
Fax Number	:	801-394-5710

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	RICH HUMPHERYS
Credential	:	O.D.
Telephone Number	:	801-394-5709

Provider Enumeration Date	:	09/11/2012
Last Update Date	:	08/23/2017

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