Provider Demographics
NPI:1720185952
Name:OPTOMETRYPRNPC
Entity Type:Organization
Organization Name:OPTOMETRYPRNPC
Other - Org Name:FAMILY CENTER VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-561-4282
Mailing Address - Street 1:914 FORT UNION BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1714
Mailing Address - Country:US
Mailing Address - Phone:801-561-4282
Mailing Address - Fax:801-561-4283
Practice Address - Street 1:914 FORT UNION BLVD
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1714
Practice Address - Country:US
Practice Address - Phone:801-561-4282
Practice Address - Fax:801-561-4283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty