Healthcare Provider Details

I. General information

NPI: 1700927043
Provider Name (Legal Business Name): MT OGDEN EYE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4360 WASHINGTON BLVD
OGDEN UT
84403-1866
US

IV. Provider business mailing address

4360 WASHINGTON BLVD
OGDEN UT
84403-1866
US

V. Phone/Fax

Practice location:
  • Phone: 801-476-0494
  • Fax: 801-476-0067
Mailing address:
  • Phone: 801-476-0494
  • Fax: 801-476-0067

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARAH HOWELL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 801-409-9900