Healthcare Provider Details

I. General information

NPI: 1457548216
Provider Name (Legal Business Name): EYE CENTER OF EPHRAIM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 E 450 N
EPHRAIM UT
84627-4027
US

IV. Provider business mailing address

43 E 450 N
EPHRAIM UT
84627-4027
US

V. Phone/Fax

Practice location:
  • Phone: 435-283-5555
  • Fax: 435-283-8642
Mailing address:
  • Phone: 435-283-5555
  • Fax: 435-283-8642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number284643-9934
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2004532
Identifier TypeOTHER
Identifier State
Identifier IssuerUNITED HEALTHCARE
# 2
Identifier328071
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerALTIUS
# 3
Identifier20005965601001
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerREGENCE BCBS - GROUP
# 4
IdentifierDN6778
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE PTAN
# 5
Identifier107008974104
Identifier TypeOTHER
Identifier State
Identifier IssuerSELECT HEALTH

VIII. Authorized Official

Name: DARIN RAY CUMMINGS
Title or Position: OWNER
Credential: O.D.
Phone: 435-283-5555