Provider Demographics
NPI:1548483019
Name:AMERICAN FORK VISION CENTER INC.
Entity type:Organization
Organization Name:AMERICAN FORK VISION CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUNNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PAXMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-756-7996
Mailing Address - Street 1:24 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2318
Mailing Address - Country:US
Mailing Address - Phone:801-756-7996
Mailing Address - Fax:
Practice Address - Street 1:24 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2318
Practice Address - Country:US
Practice Address - Phone:801-756-7996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT528111273016Medicaid
UTU21503Medicare UPIN
UT0842110001Medicare NSC
UT000090170Medicare PIN