MEDICARE: SPECIALIZED OPTICAL COMPANY

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	:	1194914010
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIALIZED OPTICAL COMPANY

Provider Business Mailing Address
First Line	:	5735 HARRISON BLVD
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4324
Country	:	US
Telephone Number	:	801-393-9440
Fax Number	:

Provider Business Practice Location Address
First Line	:	5735 HARRISON BLVD
Second Line	:
City	:	SOUTH OGDEN
State	:	UT
Zip	:	84403-4324
Country	:	US
Telephone Number	:	801-393-9440
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ROSS CLAUSSE
Credential	:	OPTICIAN
Telephone Number	:	801-393-9440

Provider Enumeration Date	:	10/16/2007
Last Update Date	:	12/12/2007

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Directions to “SPECIALIZED OPTICAL COMPANY ” Practice Location

Language	Start Address	Practice Location

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