Healthcare Provider Details

I. General information

NPI: 1215283247
Provider Name (Legal Business Name): OPTICAL LAND,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 E 4370 S SUITE 7
MURRAY UT
84107
US

IV. Provider business mailing address

153 E 4370 S SUITE 7
MURRAY UT
84107-2624
US

V. Phone/Fax

Practice location:
  • Phone: 801-281-1001
  • Fax:
Mailing address:
  • Phone: 801-281-1001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. JAE H CHOI
Title or Position: MEMBER
Credential:
Phone: 801-281-1001