Healthcare Provider Details

I. General information

NPI: 1467553990
Provider Name (Legal Business Name): STANDARD OPTICAL CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 09/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W 5TH S
BOUNTIFUL UT
84010-6232
US

IV. Provider business mailing address

1901 W PARKWAY BLVD
SALT LAKE CITY UT
84119
US

V. Phone/Fax

Practice location:
  • Phone: 801-292-0479
  • Fax: 801-292-7019
Mailing address:
  • Phone: 801-886-2020
  • Fax: 801-954-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateUT

VIII. Authorized Official

Name: KEN ACKER
Title or Position: CFO
Credential: CPA
Phone: 801-886-2020