Provider Demographics
NPI:1396919809
Name:SOUTHERN UTAH EYE CARE INC
Entity type:Organization
Organization Name:SOUTHERN UTAH EYE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-673-3201
Mailing Address - Street 1:10 DIAGONAL ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-2878
Mailing Address - Country:US
Mailing Address - Phone:435-673-3201
Mailing Address - Fax:435-673-3225
Practice Address - Street 1:10 DIAGONAL ST
Practice Address - Street 2:STE 101
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-2878
Practice Address - Country:US
Practice Address - Phone:435-673-3201
Practice Address - Fax:435-673-3225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2012-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT91113354152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528942447004Medicaid
UT529069554007Medicaid
UT0454150001Medicare NSC