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General NPI Number Information
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NPI Number | 1043633480
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Entity Type | Organization
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Legal Business Name | ADVANCED VISION & WELLNESS CLINIC
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Dates
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Enumeration Date | 01/21/2014
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Last Update Date | 01/21/2014
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Provider Practice Location Address
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Address Line | 298 24TH ST SUITE 315
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City | OGDEN
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State | UT
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Zip | 84401-1431
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Country | US
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Telephone | 801-393-4413
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Fax |
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Provider Business Mailing Address
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Address Line | 298 24TH ST SUITE 315
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City | OGDEN
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State | UT
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Zip | 84401-1431
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Country | US
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Telephone | 801-393-4413
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. DAVID BOYLE BURNETT
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Credential | O.D.
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Telephone | 801-393-4413
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 56760929934
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License Number State | UT
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