Provider Demographics
NPI:1336349380
Name:RIVERTON FAMILY EYE CARE OPTOMETRY PRACTICE , LLC
Entity Type:Organization
Organization Name:RIVERTON FAMILY EYE CARE OPTOMETRY PRACTICE , LLC
Other - Org Name:RIVERTON FAMILY EYE CARE, OPTOMETRY
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-446-7600
Mailing Address - Street 1:2998 W 12600 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-7164
Mailing Address - Country:US
Mailing Address - Phone:801-446-7600
Mailing Address - Fax:801-446-0912
Practice Address - Street 1:2998 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7164
Practice Address - Country:US
Practice Address - Phone:801-446-7600
Practice Address - Fax:801-446-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTE66160152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT526949225003Medicaid
UT5243320001Medicare NSC
UT000055611Medicare PIN