Healthcare Provider Details

I. General information

NPI: 1114100740
Provider Name (Legal Business Name): JACKSON EYE CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 E 400 N SUITE 4A
CEDAR CITY UT
84720-2686
US

IV. Provider business mailing address

PO BOX 1574
CEDAR CITY UT
84721-1574
US

V. Phone/Fax

Practice location:
  • Phone: 435-586-1500
  • Fax: 435-865-0784
Mailing address:
  • Phone: 435-586-1500
  • Fax: 435-865-0784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number375344-9934
License Number StateUT

VIII. Authorized Official

Name: DR. RUSSELL B JACKSON
Title or Position: OWNER OPERATOR
Credential: OD
Phone: 435-586-1500