Basic Information
| Provider Information | |||||||||
| NPI: | 1518117407 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RETINA AND VITREOUS SURGEONS OF UTAH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 300 W | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577704 | ||||||||
| FaxNumber: | 8013577424 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 N 300 W STE 210 | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577704 | ||||||||
| FaxNumber: | 8013577424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2008 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | COREY | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8013577704 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.