Provider Demographics
NPI:1073996344
Name:ST GEORGE EYE CENTER LLC
Entity Type:Organization
Organization Name:ST GEORGE EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:W
Authorized Official - Last Name:HENDRIX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-628-4507
Mailing Address - Street 1:1054 E RIVERSIDE DR
Mailing Address - Street 2:201
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-4825
Mailing Address - Country:US
Mailing Address - Phone:435-628-4507
Mailing Address - Fax:435-628-3748
Practice Address - Street 1:1054 E RIVERSIDE DR
Practice Address - Street 2:201
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-4825
Practice Address - Country:US
Practice Address - Phone:435-628-4507
Practice Address - Fax:435-628-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375881-9934152W00000X
UT6160962-1205207W00000X
UT7154752-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty