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General NPI Number Information
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NPI Number | 1801316138
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Entity Type | Organization
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Legal Business Name | BOSTER VISION, LLC
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Dates
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Enumeration Date | 06/27/2017
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Last Update Date | 06/27/2017
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Provider Practice Location Address
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Address Line | 4848 S 900 W
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City | RIVERDALE
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State | UT
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Zip | 84405-3726
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Country | US
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Telephone | 801-404-2825
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Fax |
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Provider Business Mailing Address
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Address Line | 2133 W 900 N
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City | FARR WEST
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State | UT
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Zip | 84404-9586
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Country | US
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Telephone | 801-404-2825
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JONATHAN BOSTER
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Credential | O.D.
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Telephone | 801-404-2825
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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 | 9051999-9934
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License Number State | UT
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