Provider Demographics
NPI:1396831483
Name:CENTRAL UTAH OPTICAL
Entity Type:Organization
Organization Name:CENTRAL UTAH OPTICAL
Other - Org Name:EXCEL EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-374-1818
Mailing Address - Street 1:1735 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1010
Mailing Address - Country:US
Mailing Address - Phone:801-374-1818
Mailing Address - Fax:801-379-2959
Practice Address - Street 1:1735 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1010
Practice Address - Country:US
Practice Address - Phone:801-374-1818
Practice Address - Fax:801-379-2959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1284570001OtherCIGNA DMERC
UT1284570001Medicare NSC