Provider Demographics
NPI:1477762805
Name:OPTOMETRIC PHYSICIANS LLC
Entity Type:Organization
Organization Name:OPTOMETRIC PHYSICIANS LLC
Other - Org Name:PLEASANT GROVE OFFICE SUB-PART
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:FROMM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-796-1054
Mailing Address - Street 1:238 E STATE RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-3620
Mailing Address - Country:US
Mailing Address - Phone:801-796-1054
Mailing Address - Fax:801-796-1084
Practice Address - Street 1:238 E STATE RD
Practice Address - Street 2:SUITE 4
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-3620
Practice Address - Country:US
Practice Address - Phone:801-796-1054
Practice Address - Fax:801-796-1084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT375345-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========002Medicaid