MEDICARE: MODERN 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	:	1407844269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN OPTICAL COMPANY

Provider Business Mailing Address
First Line	:	1548 EAST 4500 SOUTH
Second Line	:	SUITE - 105
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117
Country	:	US
Telephone Number	:	801-277-4690
Fax Number	:	801-277-4690

Provider Business Practice Location Address
First Line	:	1548 EAST 4500 SOUTH
Second Line	:	SUITE - 105
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117
Country	:	US
Telephone Number	:	801-277-4690
Fax Number	:	801-277-4690

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ROBERT WALKER FEHR SR.
Credential	:
Telephone Number	:	801-277-4690

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	05/28/2014

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Directions to “MODERN OPTICAL COMPANY ” Practice Location

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