Provider Demographics
NPI:1972685402
Name:LANNY F DUCLOS OD PC
Entity Type:Organization
Organization Name:LANNY F DUCLOS OD PC
Other - Org Name:EYE HEALTH PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LANNY
Authorized Official - Middle Name:F
Authorized Official - Last Name:DUCLOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:1435-882-6452
Mailing Address - Street 1:88 E 700 N
Mailing Address - Street 2:SUITE A
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-1818
Mailing Address - Country:US
Mailing Address - Phone:435-882-6452
Mailing Address - Fax:435-882-3170
Practice Address - Street 1:88 E 700 N
Practice Address - Street 2:SUITE A
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1818
Practice Address - Country:US
Practice Address - Phone:435-882-6452
Practice Address - Fax:435-882-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT113879-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528118588003Medicaid
UT0005327246OtherAETNA
UT101001656101OtherSELECT HEALTH
UT10898Medicaid
UT17036OtherHOMETOWN HEALTH
UT80314Medicaid
UT258200OtherDMBA
UTW0620Medicaid
NV100510174Medicaid
UTTPRA06734Medicaid
UT10898Medicaid
UT258200OtherDMBA
UTU39082Medicare UPIN
UTW0620Medicaid
UT528118588003Medicaid
UTTPRA06734Medicaid
UT6054690001Medicare NSC