Provider Demographics
NPI:1225330673
Name:NORTHERN UTAH EYE CENTER
Entity Type:Organization
Organization Name:NORTHERN UTAH EYE CENTER
Other - Org Name:THE OPTICAL SHOPPE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:NILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-752-2020
Mailing Address - Street 1:550 E 1400 N STE T
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2407
Mailing Address - Country:US
Mailing Address - Phone:435-752-2020
Mailing Address - Fax:435-752-5475
Practice Address - Street 1:550 E 1400 N STE T
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2407
Practice Address - Country:US
Practice Address - Phone:435-752-2020
Practice Address - Fax:435-752-5475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN UTAH EYE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-17
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8127835-9934152W00000X
UT6962612-1205332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1932321460Medicaid
UT1932321460Medicaid