Healthcare Provider Details

I. General information

NPI: 1518117407
Provider Name (Legal Business Name): RETINA AND VITREOUS SURGEONS OF UTAH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 500
PROVO UT
84604-3312
US

IV. Provider business mailing address

1055 N 300 W STE 500
PROVO UT
84604-3312
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7704
  • Fax: 801-357-7424
Mailing address:
  • Phone: 801-357-7704
  • Fax: 801-357-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD P COREY
Title or Position: PRESIDENT
Credential: M.D.
Phone: 801-357-7704