Provider Demographics
NPI:1366517831
Name:WOLCOTT OPTICAL SERVICE LC
Entity type:Organization
Organization Name:WOLCOTT OPTICAL SERVICE LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-485-4474
Mailing Address - Street 1:3145 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3043
Mailing Address - Country:US
Mailing Address - Phone:801-485-4474
Mailing Address - Fax:
Practice Address - Street 1:3145 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3043
Practice Address - Country:US
Practice Address - Phone:801-485-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT0373450002Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER