MEDICARE: DR. RICH H HUMPHERYS O.D.

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	111347-8908	UT

General Provider Information

NPI Number	:	1275569444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICH H HUMPHERYS O.D.

Provider Business Mailing Address
First Line	:	1055 N WASHINGTON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3605
Country	:	US
Telephone Number	:	801-394-5709
Fax Number	:	801-394-5710

Provider Business Practice Location Address
First Line	:	1055 N WASHINGTON BLVD
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84404-3605
Country	:	US
Telephone Number	:	801-394-5709
Fax Number	:	801-394-5710

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	07/08/2007

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