Healthcare Provider Details

I. General information

NPI: 1063166114
Provider Name (Legal Business Name): COOK FAMILY EYECARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2022
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 W 1600 N
OREM UT
84057-2556
US

IV. Provider business mailing address

4101 N 190 W
PROVO UT
84604-6218
US

V. Phone/Fax

Practice location:
  • Phone: 801-210-9339
  • Fax: 801-960-2887
Mailing address:
  • Phone: 208-360-3371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JEFFREY GEORGE COOK
Title or Position: OWNER
Credential: OD
Phone: 208-360-3371