MEDICARE: MOBILE EYECARE OF UTAH 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	152W00000X	Optometrist	3758049934	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

General Provider Information

NPI Number	:	1245274521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE EYECARE OF UTAH LLC

Provider Business Mailing Address
First Line	:	3665 S 8400 W
Second Line	:	SUITE 100
City	:	MAGNA
State	:	UT
Zip	:	84044-2214
Country	:	US
Telephone Number	:	801-250-5745
Fax Number	:	801-250-5981

Provider Business Practice Location Address
First Line	:	3665 S 8400 W
Second Line	:	SUITE 100
City	:	MAGNA
State	:	UT
Zip	:	84044-2214
Country	:	US
Telephone Number	:	801-250-5745
Fax Number	:	801-250-5981

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHAUN DEAN LARSEN
Credential	:	O.D.
Telephone Number	:	801-250-5745

Provider Enumeration Date	:	06/16/2006
Last Update Date	:	08/26/2010

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Directions to “MOBILE EYECARE OF UTAH LLC ” Practice Location

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