Provider Demographics
NPI:1023242435
Name:STANDARD OPTICAL CO
Entity type:Organization
Organization Name:STANDARD OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-886-2020
Mailing Address - Street 1:1901 W PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-2001
Mailing Address - Country:US
Mailing Address - Phone:801-886-2020
Mailing Address - Fax:801-954-0054
Practice Address - Street 1:1438 E MAIN ST
Practice Address - Street 2:#4
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-3797
Practice Address - Country:US
Practice Address - Phone:801-753-7909
Practice Address - Fax:801-753-7996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1023242435Medicaid
UT1023242435Medicaid
UTU00009602Medicare PIN