Healthcare Provider Details

I. General information

NPI: 1194577510
Provider Name (Legal Business Name): COLLIN R GRAY, OD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W STATE ST
LEHI UT
84043-1546
US

IV. Provider business mailing address

75 W STATE ST
LEHI UT
84043-1546
US

V. Phone/Fax

Practice location:
  • Phone: 801-768-4100
  • Fax: 801-768-0600
Mailing address:
  • Phone: 801-768-4100
  • Fax: 801-768-0600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. COLLIN R GRAY
Title or Position: OWNER
Credential: OD
Phone: 801-768-4100