Provider Demographics
NPI:1043702046
Name:EYE PROS OF LOGAN LLC
Entity Type:Organization
Organization Name:EYE PROS OF LOGAN LLC
Other - Org Name:EYE PROS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LAVAR
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:KOFOED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-447-9965
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:208-297-7019
Mailing Address - Fax:
Practice Address - Street 1:1475 N MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:208-501-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty