Provider Demographics
NPI:1558944538
Name:LEGACY VISION GROUP DBA ELEVATION EYEWORKS
Entity Type:Organization
Organization Name:LEGACY VISION GROUP DBA ELEVATION EYEWORKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:ELI
Authorized Official - Last Name:PEBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-732-8200
Mailing Address - Street 1:4645 MIDLAND DR STE A
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-6824
Mailing Address - Country:US
Mailing Address - Phone:801-792-8200
Mailing Address - Fax:801-732-8213
Practice Address - Street 1:4645 MIDLAND DR STE A
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-6824
Practice Address - Country:US
Practice Address - Phone:801-792-8200
Practice Address - Fax:801-732-8213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY VISION GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty