Provider Demographics
NPI:1609304880
Name:MODERN VISION LLC
Entity Type:Organization
Organization Name:MODERN VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, OWNER, OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-919-5154
Mailing Address - Street 1:1043 N 1000 W
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3897
Mailing Address - Country:US
Mailing Address - Phone:801-919-5154
Mailing Address - Fax:
Practice Address - Street 1:3571 W SOUTH JORDAN PKWY
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-7173
Practice Address - Country:US
Practice Address - Phone:801-523-5303
Practice Address - Fax:801-523-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-01
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty