Provider Demographics
NPI:1881801504
Name:EASTERN UTAH EYE PHYSICIANS
Entity type:Organization
Organization Name:EASTERN UTAH EYE PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LYNELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-637-8689
Mailing Address - Street 1:200 N FAIRGROUNDS RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-4205
Mailing Address - Country:US
Mailing Address - Phone:435-637-8689
Mailing Address - Fax:435-637-1123
Practice Address - Street 1:200 N FAIRGROUNDS RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PRICE
Practice Address - State:UT
Practice Address - Zip Code:84501-4205
Practice Address - Country:US
Practice Address - Phone:435-637-8689
Practice Address - Fax:435-637-1123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT289301-1205174400000X, 156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmicGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000055722Medicare ID - Type UnspecifiedGROUP #
UT1129410001Medicare NSC