Provider Demographics
NPI:1740431428
Name:MT OGDEN EYE CENTER LLC
Entity type:Organization
Organization Name:MT OGDEN EYE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-409-9900
Mailing Address - Street 1:PO BOX 30015
Mailing Address - Street 2:DEPT 93
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0015
Mailing Address - Country:US
Mailing Address - Phone:801-409-9900
Mailing Address - Fax:801-409-9901
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:SUITE 340
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-409-9900
Practice Address - Fax:801-409-9901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT176195-1205207W00000X
UT2012-42863332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000055895Medicare PIN
UT4280990002Medicare NSC