MEDICARE: PEARLE VISION INC

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	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1174687354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARLE VISION INC

Provider Business Mailing Address
First Line	:	3601 CONSTITUTION BLVD
Second Line	:	VALLEY FAIR MALL
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-3746
Country	:	US
Telephone Number	:	801-967-9048
Fax Number	:	801-967-2733

Provider Business Practice Location Address
First Line	:	3601 CONSTITUTION BLVD
Second Line	:	VALLEY FAIR MALL
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84119-3746
Country	:	US
Telephone Number	:	801-967-9048
Fax Number	:	801-967-2733

Authorized Official
Title or Position	:	MEDICARE SUPERVISOR
Name	:	MS. WENDY UHLS
Credential	:
Telephone Number	:	513-765-3534

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	08/22/2020

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