1386800639 NPI number — STANDARD OPTICAL

Table of content: DR. KEITH PATRICK SHOPA MD (NPI 1639750144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386800639 NPI number — STANDARD OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANDARD OPTICAL
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:
1386800639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 WEST 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:
801-934-0054

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1656 WEST 9000 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST JORDAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84088
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-255-5454
Provider Business Practice Location Address Fax Number:
801-255-1109
Provider Enumeration Date:
08/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ACKER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
801-886-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  56820809934 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 999000797009 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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