Provider Demographics
NPI:1568298768
Name:EYE PROS SPANISH FORK LLC
Entity type:Organization
Organization Name:EYE PROS SPANISH FORK LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:LAVAR
Authorized Official - Middle Name:
Authorized Official - Last Name:KOFOED
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-447-9965
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:833-776-2020
Mailing Address - Fax:208-297-7518
Practice Address - Street 1:846 EXPRESSWAY LN
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1300
Practice Address - Country:US
Practice Address - Phone:833-776-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-12
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty