Healthcare Provider Details

I. General information

NPI: 1356516801
Provider Name (Legal Business Name): ROBERT E. BALDWIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 N MAIN ST
LOGAN UT
84341-2215
US

IV. Provider business mailing address

1097 N MAIN ST
LOGAN UT
84341-2215
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-6110
  • Fax: 435-752-1935
Mailing address:
  • Phone: 435-752-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number112533-9934
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number08-00959
License Number StateUT

VIII. Authorized Official

Name: MR. ROBERT E. BALDWIN
Title or Position: OWNER
Credential:
Phone: 435-752-6110