Provider Demographics
NPI:1700022688
Name:ABUNDO EYE CARE LLC
Entity Type:Organization
Organization Name:ABUNDO EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:ESPELETA
Authorized Official - Last Name:ABUNDO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-255-8500
Mailing Address - Street 1:579 FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2213
Mailing Address - Country:US
Mailing Address - Phone:801-255-8500
Mailing Address - Fax:801-255-2334
Practice Address - Street 1:579 FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2213
Practice Address - Country:US
Practice Address - Phone:801-255-8500
Practice Address - Fax:801-255-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-26
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3097889934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT5700550715003Medicaid
UT000012762Medicare PIN