STANDARD OPTICAL CO

Provider Demographics

• NPI: 1174624787
• Name: STANDARD OPTICAL CO
• Entity type: Organization
• Organization Name: STANDARD OPTICAL CO
• Authorized Official - Title/Position: OFFICE MANAGER
• Authorized Official - First Name: ALYSA
• Authorized Official - Last Name: WOODS
• Authorized Official - Phone: 801-886-2020
• Mailing Address - Street 1: 1901 W PARKWAY BLVD
• Mailing Address - City: SALT LAKE CITY
• Mailing Address - State: UT
• Mailing Address - Zip Code: 84119
• Mailing Address - Country: US
• Mailing Address - Phone: 801-886-2020
• Mailing Address - Fax: 801-954-0054
• Practice Address - Street 1: 1901 W PARKWAY BLVD
• Practice Address - City: SALT LAKE CITY
• Practice Address - State: UT
• Practice Address - Zip Code: 84119
• Practice Address - Country: US
• Practice Address - Phone: 801-886-2020
• Practice Address - Fax: 801-954-0054
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-09-26
• Last Update Date: 2018-01-30

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	152W00000X	Eye and Vision Services Providers	Optometrist		Group - Multi-Specialty
No	207W00000X	Allopathic & Osteopathic Physicians	Ophthalmology		Group - Multi-Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
UT	999000797009	Medicaid
UT	1700082104	Other	MEDICAID (WYATT)
UT	PRA03404	Other	MOLINA MEDICAID
UT	0618950009	Medicare NSC
UT	PRA03404	Other	MOLINA MEDICAID
UT	U000009923	Medicare PIN
UT	0618950004	Medicare NSC
UT	U000009926	Medicare PIN
UT	U000009542	Medicare PIN
UT	U000009430	Medicare PIN
UT	U000004615	Medicare PIN
UT	U000004473	Medicare PIN
UT	0618950012	Medicare NSC
UT	U000009922	Medicare PIN
UT	999000797009	Medicaid
UT	0618950008	Medicare NSC
UT	0618950019	Medicare NSC
UT	0618950011	Medicare NSC
UT	U000009602	Medicare PIN
UT	000090374	Medicare PIN
UT	000057630	Medicare PIN
UT	000009105	Medicare PIN
UT	0618950018	Medicare NSC
UT	000009308	Medicare PIN
UT	0618950005	Medicare NSC
UT	0618950002	Medicare NSC
UT	0618950014	Medicare NSC
UT	U000004481	Medicare PIN
UT	000057015	Medicare PIN
UT	0618950003	Medicare NSC
UT	0618950016	Medicare NSC
UT	0618950017	Medicare NSC
UT	0618950010	Medicare NSC
UT	U000009763	Medicare PIN