Provider Demographics
NPI:1346608619
Name:SLC WALMART EYE DOCS
Entity Type:Organization
Organization Name:SLC WALMART EYE DOCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-502-7394
Mailing Address - Street 1:9067 S BORDEAUX WAY
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2216
Mailing Address - Country:US
Mailing Address - Phone:801-502-7394
Mailing Address - Fax:
Practice Address - Street 1:3590 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8916
Practice Address - Country:US
Practice Address - Phone:801-601-3131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354412-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty