Full Name | |
---|---|
Type | Facility |
Speciality | Optometrist |
Location | 210 S 100 W, Fillmore, Utah |
Accepts Medicare Assignments | Does not participate in Medicare Program. The facility may not accept medicare assignment. |
Identifier | Type | State | Issuer |
---|---|---|---|
1912181967 | NPI | - | NPPES |
528882505001 | Medicaid | UT |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
152W00000X | Optometrist | 375344-9934 (Utah) | Primary |
Mailing Address | Practice Location Address |
---|---|
Po Box 73, Fillmore, UT 84631-0073 Ph: (435) 743-6572 | 210 S 100 W, Fillmore, UT 84631 Ph: (435) 743-6572 |
Russell B Jackson, OD Optometrist Medicare: Not Enrolled in Medicare Practice Location: 210 S 100 E, Fillmore, UT 84631 Phone: 435-743-6572 Fax: 435-743-5558 |