Provider Demographics
NPI:1952840829
Name:VISION HEALTH CENTER INCE
Entity Type:Organization
Organization Name:VISION HEALTH CENTER INCE
Other - Org Name:PARK CITY VISION SOURCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASTLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-649-5200
Mailing Address - Street 1:6584 N CREEKSIDE LN
Mailing Address - Street 2:STE 150
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5896
Mailing Address - Country:US
Mailing Address - Phone:435-649-5200
Mailing Address - Fax:435-649-2644
Practice Address - Street 1:6584 N CREEKSIDE LN
Practice Address - Street 2:STE 150
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5896
Practice Address - Country:US
Practice Address - Phone:435-649-5200
Practice Address - Fax:435-649-2644
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISION HEALTH CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-13
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7960144-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU0000079697Medicare UPIN