MEDICARE: STANDARD OPTICAL CO

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	207W00000X	Ophthalmology Physician		UT
2	152W00000X	Optometrist		UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	269929	OTHER	UT	ALTIUS
3	920555	OTHER	UT	DMBA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043311582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STANDARD OPTICAL CO

Provider Business Mailing Address
First Line	:	1901 W PARKWAY BLVD
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84119
Country	:	US
Telephone Number	:	801-886-2020
Fax Number	:	801-954-0054

Provider Business Practice Location Address
First Line	:	4878 HIGHLAND DR
Second Line	:	CREEKSIDE PLAZA
City	:	HOLLADAY
State	:	UT
Zip	:	84117-6007
Country	:	US
Telephone Number	:	801-272-8861
Fax Number	:	801-272-8867

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ALYSA WOODS
Credential	:
Telephone Number	:	801-886-2020

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	03/23/2021

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Directions to “STANDARD OPTICAL CO ” Practice Location

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