Provider Demographics
NPI:1104150770
Name:TERRY M HANSEN OD LLC
Entity type:Organization
Organization Name:TERRY M HANSEN OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:MILO
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-966-6201
Mailing Address - Street 1:2828 W 4700 S
Mailing Address - Street 2:SUITE D
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-2154
Mailing Address - Country:US
Mailing Address - Phone:801-966-6201
Mailing Address - Fax:801-966-6609
Practice Address - Street 1:2828 W 4700 S
Practice Address - Street 2:SUITE D
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-2154
Practice Address - Country:US
Practice Address - Phone:801-966-6201
Practice Address - Fax:801-966-6609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT109507-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty