1043311582 NPI number — STANDARD OPTICAL CO

Table of content: (NPI 1043311582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043311582 NPI number — STANDARD OPTICAL CO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANDARD OPTICAL CO
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043311582
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 W PARKWAY BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84119
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-886-2020
Provider Business Mailing Address Fax Number:
801-954-0054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4878 HIGHLAND DR
Provider Second Line Business Practice Location Address:
CREEKSIDE PLAZA
Provider Business Practice Location Address City Name:
HOLLADAY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84117-6007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-272-8861
Provider Business Practice Location Address Fax Number:
801-272-8867
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
ALYSA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
801-886-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207W00000X , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 999000797009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 269929 . This is a "ALTIUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 920555 . This is a "DMBA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 1043311582 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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