Provider Demographics
NPI:1467964924
Name:CEDAR OPTHALMIC ASSOCIATES PLLC
Entity Type:Organization
Organization Name:CEDAR OPTHALMIC ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRONNING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-586-1131
Mailing Address - Street 1:1811 W ROYAL HUNTE DR STE 1
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-8174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1811 W ROYAL HUNTE DR STE 1
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-8174
Practice Address - Country:US
Practice Address - Phone:435-586-1131
Practice Address - Fax:435-865-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT52804678808Medicaid
UT519861128011Medicaid