Provider Demographics
NPI:1972786572
Name:CLASSIC OPTICAL
Entity Type:Organization
Organization Name:CLASSIC OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:WIRTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-261-2020
Mailing Address - Street 1:192 E 4500 S
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2628
Mailing Address - Country:US
Mailing Address - Phone:801-261-2020
Mailing Address - Fax:801-261-2052
Practice Address - Street 1:192 E 4500 S
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-2628
Practice Address - Country:US
Practice Address - Phone:801-261-2020
Practice Address - Fax:801-261-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1092209934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT567804848008Medicaid
UT567804848008Medicaid