Provider Demographics
NPI:1366645954
Name:LAYTON VISUAL CENTER
Entity Type:Organization
Organization Name:LAYTON VISUAL CENTER
Other - Org Name:LAYTON VISUAL CENTER, INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENMARK
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-546-2481
Mailing Address - Street 1:180 WEST GORDON AVE
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041
Mailing Address - Country:US
Mailing Address - Phone:801-546-2481
Mailing Address - Fax:801-546-2483
Practice Address - Street 1:180 WEST GORDON AVE
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041
Practice Address - Country:US
Practice Address - Phone:801-546-2481
Practice Address - Fax:801-546-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT108553-8908152WL0500X, 152WP0200X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WX0102XEye and Vision Services ProvidersOptometristOccupational VisionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT529461401004Medicaid
UTT79466Medicare UPIN
UT529461401004Medicaid