Provider Demographics
NPI:1255008868
Name:ADVANCED EYE PROSTHETICS LLC
Entity Type:Organization
Organization Name:ADVANCED EYE PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-362-0599
Mailing Address - Street 1:3305 W MAYFLOWER WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3305 W MAYFLOWER WAY STE 4
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-2961
Practice Address - Country:US
Practice Address - Phone:801-362-0599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Single Specialty