Healthcare Provider Details

I. General information

NPI: 1225330673
Provider Name (Legal Business Name): NORTHERN UTAH EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 E 1400 N STE T
LOGAN UT
84341-2407
US

IV. Provider business mailing address

550 E 1400 N STE T
LOGAN UT
84341-2407
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-2020
  • Fax: 435-752-5475
Mailing address:
  • Phone: 435-752-2020
  • Fax: 435-752-5475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number6962612-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number8127835-9934
License Number StateUT

VIII. Authorized Official

Name: DR. CHRISTIAN D NILSON
Title or Position: OWNER
Credential: M.D.
Phone: 435-752-2020