Provider Demographics
NPI:1528299245
Name:SOUTH VALLEY EYECARE CENTER, INC.
Entity type:Organization
Organization Name:SOUTH VALLEY EYECARE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:435-713-4444
Mailing Address - Street 1:276 SPRINGCREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332
Mailing Address - Country:US
Mailing Address - Phone:435-713-4444
Mailing Address - Fax:435-787-1238
Practice Address - Street 1:276 SPRINGCREEK PKWY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:435-713-4444
Practice Address - Fax:435-787-1238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-29
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346644-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT615808OtherDMBA
UTQM0000053383OtherALTIUS
UT51811974400001OtherBLUE CROSS BLUE SHIELD
UT518119744008Medicaid
UT518119744008Medicaid
UT615808OtherDMBA