Provider Demographics
NPI:1336336080
Name:EYE CLINIC & CONTACT LENS CENTER OF UTAH VALLEY PC
Entity Type:Organization
Organization Name:EYE CLINIC & CONTACT LENS CENTER OF UTAH VALLEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:K
Authorized Official - Last Name:MONSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-373-4550
Mailing Address - Street 1:2230 N UNIVERSITY PKWY STE 10A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1594
Mailing Address - Country:US
Mailing Address - Phone:801-373-4550
Mailing Address - Fax:
Practice Address - Street 1:2230 N UNIVERSITY PKWY STE 10A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1594
Practice Address - Country:US
Practice Address - Phone:801-373-4550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109118-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT519502484001Medicaid
UT519502484001Medicaid
UTT78135Medicare UPIN
UT0823890001Medicare NSC