Healthcare Provider Details

I. General information

NPI: 1396831483
Provider Name (Legal Business Name): CENTRAL UTAH OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 N STATE ST
PROVO UT
84604-1010
US

IV. Provider business mailing address

1735 NORTH STATE STREET
PROVO UT
84604-1010
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-1818
  • Fax: 801-379-2959
Mailing address:
  • Phone: 801-374-1818
  • Fax: 801-379-2959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. RON DUNN
Title or Position: ADMINISTRATOR
Credential:
Phone: 801-374-1818