MEDICARE: SUGARHOUSE VISION CLINIC

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	1932292281	UT

General Provider Information

NPI Number	:	1912100348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGARHOUSE VISION CLINIC

Provider Business Mailing Address
First Line	:	2178 S 900 E STE 4
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2388
Country	:	US
Telephone Number	:	801-484-2020
Fax Number	:	801-466-2865

Provider Business Practice Location Address
First Line	:	2178 S 900 E STE 4
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2388
Country	:	US
Telephone Number	:	801-484-2020
Fax Number	:	801-466-2865

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TODD KIMBALL
Credential	:	O.D.
Telephone Number	:	801-484-2020

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	06/14/2016

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