Healthcare Provider Details

I. General information

NPI: 1245558519
Provider Name (Legal Business Name): EYECARE WELLNESS CLINIC P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4848 S 900 W
RIVERDALE UT
84405-3726
US

IV. Provider business mailing address

174 OAKRIDGE DR
FARMINGTON UT
84025-3625
US

V. Phone/Fax

Practice location:
  • Phone: 801-627-9868
  • Fax: 801-627-9870
Mailing address:
  • Phone: 801-627-9868
  • Fax: 801-627-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5676092-9934
License Number StateUT

VIII. Authorized Official

Name: DR. DAVID BOYLE BURNETT
Title or Position: PRESIDENT
Credential: O.D.
Phone: 801-309-4832