Provider Demographics
NPI:1245274521
Name:MOBILE EYECARE OF UTAH LLC
Entity type:Organization
Organization Name:MOBILE EYECARE OF UTAH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-250-5745
Mailing Address - Street 1:3665 S 8400 W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MAGNA
Mailing Address - State:UT
Mailing Address - Zip Code:84044-2214
Mailing Address - Country:US
Mailing Address - Phone:801-250-5745
Mailing Address - Fax:801-250-5981
Practice Address - Street 1:3665 S 8400 W
Practice Address - Street 2:SUITE 100
Practice Address - City:MAGNA
Practice Address - State:UT
Practice Address - Zip Code:84044-2214
Practice Address - Country:US
Practice Address - Phone:801-250-5745
Practice Address - Fax:801-250-5981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3758049934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528455690016Medicaid
UT000057039Medicare ID - Type Unspecified
UT528455690016Medicaid
UT000055995Medicare ID - Type Unspecified
UT4905670001Medicare NSC