Healthcare Provider Details

I. General information

NPI: 1568298768
Provider Name (Legal Business Name): EYE PROS SPANISH FORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

846 EXPRESSWAY LN
SPANISH FORK UT
84660-1300
US

IV. Provider business mailing address

3485 N COLE RD UNIT 45479
BOISE ID
83711-1095
US

V. Phone/Fax

Practice location:
  • Phone: 833-776-2020
  • Fax:
Mailing address:
  • Phone: 833-776-2020
  • Fax: 208-297-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LAVAR KOFOED
Title or Position: OWNER/ OPTOMETRIST
Credential: OD
Phone: 208-447-9965