Provider Demographics
NPI:1013910397
Name:PURCELL, LYNN REX (OD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:REX
Last Name:PURCELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-0155
Mailing Address - Country:US
Mailing Address - Phone:435-257-7436
Mailing Address - Fax:435-257-6229
Practice Address - Street 1:495 W 600 N
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-2411
Practice Address - Country:US
Practice Address - Phone:435-257-7436
Practice Address - Fax:435-257-6229
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT111108-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009733Medicare ID - Type Unspecified
UTT78169Medicare UPIN
UT0646950001Medicare NSC