Provider Demographics
NPI:1336294750
Name:EYE CARE FOR KIDS
Entity Type:Organization
Organization Name:EYE CARE FOR KIDS
Other - Org Name:EYE CARE 4 KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC, NCLC
Authorized Official - Phone:801-255-8525
Mailing Address - Street 1:6895 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1259
Mailing Address - Country:US
Mailing Address - Phone:801-255-8525
Mailing Address - Fax:801-255-8526
Practice Address - Street 1:6911 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1239
Practice Address - Country:US
Practice Address - Phone:801-255-8525
Practice Address - Fax:801-255-8526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact LensGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPRA06546Medicaid