Healthcare Provider Details

I. General information

NPI: 1144484718
Provider Name (Legal Business Name): SPECTRUM EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2008
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E MAIN ST STE E
GRANTSVILLE UT
84029-9030
US

IV. Provider business mailing address

225 E MAIN ST STE E
GRANTSVILLE UT
84029-9030
US

V. Phone/Fax

Practice location:
  • Phone: 435-884-6562
  • Fax:
Mailing address:
  • Phone: 435-884-6562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6630201-9934
License Number StateUT

VIII. Authorized Official

Name: DR. RYAN S ORGILL
Title or Position: MANAGER
Credential: O.D.
Phone: 435-884-6562