Healthcare Provider Details

I. General information

NPI: 1407470040
Provider Name (Legal Business Name): EYE DOCTOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 05/29/2020
Certification Date: 05/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5331 ADAMS AVE PKWY STE B
OGDEN UT
84405-4755
US

IV. Provider business mailing address

11187 S 2865 W
SOUTH JORDAN UT
84095-8438
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-7850
  • Fax: 801-479-7825
Mailing address:
  • Phone: 801-910-6063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEREMIAH V CHURCH
Title or Position: OPTOMETRIST
Credential: OD
Phone: 801-479-7850