Provider Demographics
NPI:1407470040
Name:EYE DOCTOR LLC
Entity Type:Organization
Organization Name:EYE DOCTOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:V
Authorized Official - Last Name:CHURCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-479-7850
Mailing Address - Street 1:11187 S 2865 W
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8438
Mailing Address - Country:US
Mailing Address - Phone:801-910-6063
Mailing Address - Fax:
Practice Address - Street 1:5331 ADAMS AVE PKWY STE B
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4755
Practice Address - Country:US
Practice Address - Phone:801-479-7850
Practice Address - Fax:801-479-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty