MEDICARE: ROOSEVELT VISION CLINIC, PC

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	111999-9934	UT

General Provider Information

NPI Number	:	1710973052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOSEVELT VISION CLINIC, PC

Provider Business Mailing Address
First Line	:	165 W 200 N
Second Line	:	71-7
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-2981
Fax Number	:	435-722-3732

Provider Business Practice Location Address
First Line	:	165 W 200 N
Second Line	:	71-7
City	:	ROOSEVELT
State	:	UT
Zip	:	84066-2834
Country	:	US
Telephone Number	:	435-722-2981
Fax Number	:	435-722-3732

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	SCOTT H KOWALLIS
Credential	:	O.D.
Telephone Number	:	435-722-2981

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	08/27/2008

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