MEDICARE: CEDAR VALLEY EYECARE, LLC

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	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1104798735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CEDAR VALLEY EYECARE, LLC

Provider Business Mailing Address
First Line	:	4317 N PONY EXPRESS PKWY
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-1230
Country	:	US
Telephone Number	:	801-768-4100
Fax Number	:	801-768-0600

Provider Business Practice Location Address
First Line	:	4317 N PONY EXPRESS PKWY
Second Line	:
City	:	EAGLE MOUNTAIN
State	:	UT
Zip	:	84005-1230
Country	:	US
Telephone Number	:	801-768-4100
Fax Number	:	801-768-0600

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	DR. COLLIN GRAY
Credential	:	OD
Telephone Number	:	801-473-5127

Provider Enumeration Date	:	09/23/2025
Last Update Date	:	09/23/2025

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