Provider Demographics
NPI:1619209673
Name:MICHAELS CLASSIC OPTICAL
Entity Type:Organization
Organization Name:MICHAELS CLASSIC OPTICAL
Other - Org Name:CLASSIC OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-261-2020
Mailing Address - Street 1:192 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2628
Mailing Address - Country:US
Mailing Address - Phone:801-261-2020
Mailing Address - Fax:801-261-2052
Practice Address - Street 1:192 E 4500 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-2628
Practice Address - Country:US
Practice Address - Phone:801-261-2020
Practice Address - Fax:801-261-2052
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONKLIN EYE CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354412-9934152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95726Medicare UPIN