MEDICARE: PROMONTORY VISION PARTNERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5704014-9934	UT

General Provider Information

NPI Number	:	1013187822
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROMONTORY VISION PARTNERS

Provider Business Mailing Address
First Line	:	1448 N 2000 W
Second Line	:	#3
City	:	CLINTON
State	:	UT
Zip	:	84015-8377
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:

Provider Business Practice Location Address
First Line	:	1448 N 2000 W
Second Line	:	SUITE 12
City	:	CLINTON
State	:	UT
Zip	:	84015-8377
Country	:	US
Telephone Number	:	801-779-0708
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CLARK FIELDEN
Credential	:	O.D.
Telephone Number	:	801-779-0708

Provider Enumeration Date	:	03/07/2008
Last Update Date	:	12/14/2015

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1871590430 — DR. DAVID D MORTENSEN OD
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Directions to “PROMONTORY VISION PARTNERS ” Practice Location

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