Provider Demographics
NPI:1043633480
Name:ADVANCED VISION & WELLNESS CLINIC
Entity Type:Organization
Organization Name:ADVANCED VISION & WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BOYLE
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-393-4413
Mailing Address - Street 1:298 24TH ST
Mailing Address - Street 2:SUITE 315
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-1431
Mailing Address - Country:US
Mailing Address - Phone:801-393-4413
Mailing Address - Fax:
Practice Address - Street 1:298 24TH ST
Practice Address - Street 2:SUITE 315
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-1431
Practice Address - Country:US
Practice Address - Phone:801-393-4413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT56760929934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty