Provider Demographics
NPI:1922282599
Name:PROGRESSIVE EYE CARE, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BROADHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-676-2020
Mailing Address - Street 1:3556 W 9800 S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3211
Mailing Address - Country:US
Mailing Address - Phone:801-676-2020
Mailing Address - Fax:801-253-6591
Practice Address - Street 1:3556 W 9800 S
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3211
Practice Address - Country:US
Practice Address - Phone:801-676-2020
Practice Address - Fax:801-253-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4826018-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528592101002Medicaid