Provider Demographics
NPI:1760612139
Name:EAST MILLCREEK EYEWEAR
Entity Type:Organization
Organization Name:EAST MILLCREEK EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCALLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:801-485-5820
Mailing Address - Street 1:3203 S 2300 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2703
Mailing Address - Country:US
Mailing Address - Phone:801-485-5820
Mailing Address - Fax:801-485-5830
Practice Address - Street 1:3203 S 2300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-2703
Practice Address - Country:US
Practice Address - Phone:801-485-5820
Practice Address - Fax:801-485-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT19242156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty