Healthcare Provider Details

I. General information

NPI: 1740431428
Provider Name (Legal Business Name): MT OGDEN EYE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1551 RENAISSANCE TOWNE DR SUITE 340
BOUNTIFUL UT
84010-7667
US

IV. Provider business mailing address

PO BOX 30015 DEPT 93
SALT LAKE CITY UT
84130-0015
US

V. Phone/Fax

Practice location:
  • Phone: 801-409-9900
  • Fax: 801-409-9901
Mailing address:
  • Phone: 801-409-9900
  • Fax: 801-409-9901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number176195-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2012-42863
License Number StateUT

VIII. Authorized Official

Name: SARAH HOWELL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 801-409-9900