=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386531846
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANDEN LONGSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2025
-----------------------------------------------------
Last Update Date | 06/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2569 S 5600 W STE A550
-----------------------------------------------------
City | WEST VALLEY CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84120-1363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-297-1773
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4473 W VERMILLION DR
-----------------------------------------------------
City | SOUTH JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84009-7778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 10076212-9934
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------