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General NPI Number Information
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NPI Number | 1568298768
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Entity Type | Organization
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Legal Business Name | EYE PROS SPANISH FORK LLC
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Dates
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Enumeration Date | 09/12/2024
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Last Update Date | 11/06/2024
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Provider Practice Location Address
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Address Line | 846 EXPRESSWAY LN
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City | SPANISH FORK
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State | UT
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Zip | 84660-1300
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Country | US
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Telephone | 833-776-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 3485 N COLE RD UNIT 45479
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City | BOISE
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State | ID
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Zip | 83711-1095
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Country | US
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Telephone | 833-776-2020
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Fax | 208-297-7518
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Authorized Official
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Title or Position | OWNER/ OPTOMETRIST
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Name | LAVAR KOFOED
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Credential | OD
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Telephone | 208-447-9965
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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 |
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License Number State |
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