Healthcare Provider Details

I. General information

NPI: 1174624787
Provider Name (Legal Business Name): STANDARD OPTICAL CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 01/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W PARKWAY BLVD
SALT LAKE CITY UT
84119
US

IV. Provider business mailing address

1901 W PARKWAY BLVD
SALT LAKE CITY UT
84119
US

V. Phone/Fax

Practice location:
  • Phone: 801-886-2020
  • Fax: 801-954-0054
Mailing address:
  • Phone: 801-886-2020
  • Fax: 801-954-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: ALYSA WOODS
Title or Position: OFFICE MANAGER
Credential:
Phone: 801-886-2020