MEDICARE: LEGACY VISION GROUP DBA ELEVATION EYEWORKS

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

General Provider Information

NPI Number	:	1558944538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY VISION GROUP DBA ELEVATION EYEWORKS

Provider Business Mailing Address
First Line	:	4645 MIDLAND DR STE A
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-6824
Country	:	US
Telephone Number	:	801-792-8200
Fax Number	:	801-732-8213

Provider Business Practice Location Address
First Line	:	4645 MIDLAND DR STE A
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-6824
Country	:	US
Telephone Number	:	801-792-8200
Fax Number	:	801-732-8213

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MITCHELL ELI PEBLEY
Credential	:	OD
Telephone Number	:	801-732-8200

Provider Enumeration Date	:	04/28/2021
Last Update Date	:	04/28/2021

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