Provider Demographics
NPI:1982722443
Name:BRENT L. HADLOCK, OD, PC
Entity Type:Organization
Organization Name:BRENT L. HADLOCK, OD, PC
Other - Org Name:PEARLE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HADLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-224-0451
Mailing Address - Street 1:1448 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-7704
Mailing Address - Country:US
Mailing Address - Phone:801-224-0451
Mailing Address - Fax:801-224-0452
Practice Address - Street 1:1448 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7704
Practice Address - Country:US
Practice Address - Phone:801-224-0451
Practice Address - Fax:801-224-0452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT110079-9934332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT519526886017Medicaid
UT519526886017Medicaid