Provider Demographics
NPI:1477632669
Name:LUND OPTICAL COMPANY
Entity Type:Organization
Organization Name:LUND OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:LUND
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:801-375-1333
Mailing Address - Street 1:20 NO UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601
Mailing Address - Country:US
Mailing Address - Phone:801-375-1333
Mailing Address - Fax:801-375-1348
Practice Address - Street 1:20 NO UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-375-1333
Practice Address - Fax:801-375-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT990002164009Medicaid
0648400001Medicare ID - Type Unspecified