Provider Demographics
NPI:1255517637
Name:WASATCH VISION CLINIC LLC
Entity type:Organization
Organization Name:WASATCH VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:CUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-328-2020
Mailing Address - Street 1:849 E 400 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2928
Mailing Address - Country:US
Mailing Address - Phone:801-328-2020
Mailing Address - Fax:801-363-2201
Practice Address - Street 1:849 E 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2928
Practice Address - Country:US
Practice Address - Phone:801-328-2020
Practice Address - Fax:801-363-2201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0738780001Medicare NSC