=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538260021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STANDARD OPTICAL CO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 09/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4305 HARRISON BLVD #9B
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84403-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-479-5060
-----------------------------------------------------
Fax | 801-479-3649
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1901 W PARKWAY BLVD
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-886-2020
-----------------------------------------------------
Fax | 801-954-0054
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KEN ACKER
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 801-886-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------