Provider Demographics
NPI:1710973052
Name:ROOSEVELT VISION CLINIC, PC
Entity Type:Organization
Organization Name:ROOSEVELT VISION CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:H
Authorized Official - Last Name:KOWALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-722-2981
Mailing Address - Street 1:165 W 200 N
Mailing Address - Street 2:71-7
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2834
Mailing Address - Country:US
Mailing Address - Phone:435-722-2981
Mailing Address - Fax:435-722-3732
Practice Address - Street 1:165 W 200 N
Practice Address - Street 2:71-7
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2834
Practice Address - Country:US
Practice Address - Phone:435-722-2981
Practice Address - Fax:435-722-3732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111999-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherVALUCARE
=========OtherIHC
=========OtherEYEMED
=========OtherUNITED HEALTH CARE
=========OtherPEHP
=========OtherVALUECARE
UT=========OtherOPTICARE
=========OtherEDUCATORS MUTUAL
=========OtherVA
UT=========OtherBLUE CROSS BLUE SHIELD
=========OtherNTCA
=========OtherVSP
=========OtherMBA
UT=========Medicaid
=========OtherAETNA
=========OtherNTCA
=========Medicare ID - Type Unspecified