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General NPI Number Information
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NPI Number | 1346608619
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Entity Type | Organization
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Legal Business Name | SLC WALMART EYE DOCS
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Dates
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Enumeration Date | 02/02/2016
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Last Update Date | 02/02/2016
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Provider Practice Location Address
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Address Line | 3590 W SOUTH JORDAN PKWY
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-8916
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Country | US
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Telephone | 801-601-3131
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Fax |
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Provider Business Mailing Address
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Address Line | 9067 S BORDEAUX WAY
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City | SANDY
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State | UT
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Zip | 84093-2216
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Country | US
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Telephone | 801-502-7394
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Fax |
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Authorized Official
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Title or Position | MBR/OPTOMETRIST
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Name | MICHAEL CONKLIN
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Credential | OD
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Telephone | 801-502-7394
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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 | 5354412-9934
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License Number State | UT
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