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General NPI Number Information
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NPI Number | 1609304880
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Entity Type | Organization
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Legal Business Name | MODERN VISION LLC
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Dates
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Enumeration Date | 06/01/2017
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Last Update Date | 06/01/2017
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Provider Practice Location Address
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Address Line | 3571 W SOUTH JORDAN PKWY
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City | SOUTH JORDAN
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State | UT
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Zip | 84095-7173
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Country | US
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Telephone | 801-523-5303
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Fax | 801-523-5301
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Provider Business Mailing Address
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Address Line | 1043 N 1000 W
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City | AMERICAN FORK
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State | UT
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Zip | 84003-3897
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Country | US
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Telephone | 801-919-5154
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Fax |
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Authorized Official
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Title or Position | MANAGER, OWNER, OPTOMETRIST
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Name | DR. SHELLY L NIELSEN
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Credential | OD
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Telephone | 801-919-5154
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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 | UT
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