Provider Demographics
NPI:1396832655
Name:STANDARD OPTICAL CO
Entity Type:Organization
Organization Name:STANDARD OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:801-886-2020
Mailing Address - Street 1:1901 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2001
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:5421 S 19TH W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067
Practice Address - Country:US
Practice Address - Phone:801-825-9703
Practice Address - Fax:801-825-5349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396832655Medicaid
UT241764OtherDMBA
UT5529OtherDMBA
UT999000797009Medicaid
UTU000009430Medicare PIN
UT0618950009Medicare NSC