=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215031620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST VALLEY EYE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3725 W 4100 S
-----------------------------------------------------
City | WEST VALLEY CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84120-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-965-3636
-----------------------------------------------------
Fax | 801-965-3559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3527 WEST 4100 SOUTH
-----------------------------------------------------
City | WEST VALLEY CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84120-5530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-965-3636
-----------------------------------------------------
Fax | 801-965-3559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ROBERT E SMITH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 801-965-3636
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 359975-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------