Provider Demographics
NPI:1689775041
Name:STANDARD OPTICAL CO
Entity Type:Organization
Organization Name:STANDARD OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:8018-860-2020
Mailing Address - Street 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:3754 W 5400 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84118-3574
Practice Address - Country:US
Practice Address - Phone:801-964-9911
Practice Address - Fax:801-964-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT999000797009Medicaid
UT1689775041Medicaid
UT999000797009Medicaid
UT1689775041Medicaid