Provider Demographics
NPI:1457389843
Name:WENDOVER EYECARE
Entity type:Organization
Organization Name:WENDOVER EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-910-4746
Mailing Address - Street 1:1414 W 11400 S
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8224
Mailing Address - Country:US
Mailing Address - Phone:801-699-2052
Mailing Address - Fax:801-250-5981
Practice Address - Street 1:479 E. WENDOVER BLVD.
Practice Address - Street 2:
Practice Address - City:WENDOVER
Practice Address - State:UT
Practice Address - Zip Code:84083
Practice Address - Country:US
Practice Address - Phone:801-699-2052
Practice Address - Fax:801-250-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3758049934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528455690016Medicaid
UT528455690016Medicaid