Provider Demographics
NPI: | 1659609279 |
---|---|
Name: | 20-20 EYECARE OF UTAH LLC |
Entity Type: | Organization |
Organization Name: | 20-20 EYECARE OF UTAH LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OPTOMETRIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RONALD |
Authorized Official - Middle Name: | SCOTT |
Authorized Official - Last Name: | ROPER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | OD |
Authorized Official - Phone: | 801-966-2020 |
Mailing Address - Street 1: | 373 BRAMBLEBERRY LN |
Mailing Address - Street 2: | |
Mailing Address - City: | DRAPER |
Mailing Address - State: | UT |
Mailing Address - Zip Code: | 84020-9412 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 801-619-8067 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3544 W 6200 S |
Practice Address - Street 2: | UNIT #104 |
Practice Address - City: | TAYLORSVILLE |
Practice Address - State: | UT |
Practice Address - Zip Code: | 84118-3205 |
Practice Address - Country: | US |
Practice Address - Phone: | 801-966-2020 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-11-19 |
Last Update Date: | 2009-11-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
UT | 51898809934 | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist | Group - Single Specialty |