Provider Demographics
NPI:1700894961
Name:KEMP OPTICAL
Entity Type:Organization
Organization Name:KEMP OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:801-374-2666
Mailing Address - Street 1:215 W 940 N
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3325
Mailing Address - Country:US
Mailing Address - Phone:801-374-2666
Mailing Address - Fax:
Practice Address - Street 1:215 W 940 N
Practice Address - Street 2:SUITE 1
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3325
Practice Address - Country:US
Practice Address - Phone:801-374-2666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========007Medicaid