Provider Demographics
NPI:1265414163
Name:RENCHER, STACY LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNN
Last Name:RENCHER
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 1:4896 S 1900 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-2994
Mailing Address - Country:US
Mailing Address - Phone:801-773-2999
Mailing Address - Fax:
Practice Address - Street 1:4896 S 1900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2994
Practice Address - Country:US
Practice Address - Phone:801-773-2999
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1125529934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T78180Medicare UPIN