Provider Demographics
NPI:1407844269
Name:MODERN OPTICAL COMPANY
Entity Type:Organization
Organization Name:MODERN OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WALKER
Authorized Official - Last Name:FEHR
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:801-277-4690
Mailing Address - Street 1:1548 EAST 4500 SOUTH
Mailing Address - Street 2:SUITE - 105
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117
Mailing Address - Country:US
Mailing Address - Phone:801-277-4690
Mailing Address - Fax:801-277-4690
Practice Address - Street 1:1548 EAST 4500 SOUTH
Practice Address - Street 2:SUITE - 105
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117
Practice Address - Country:US
Practice Address - Phone:801-277-4690
Practice Address - Fax:801-277-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0147060001Medicare ID - Type Unspecified