Provider Demographics
NPI:1043509888
Name:LEGACY VISION GROUP
Entity type:Organization
Organization Name:LEGACY VISION GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-732-8200
Mailing Address - Street 1:4645 S. MIDLAND DR.
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401
Mailing Address - Country:US
Mailing Address - Phone:801-732-8200
Mailing Address - Fax:801-732-8213
Practice Address - Street 1:4645 S. MIDLAND DR.
Practice Address - Street 2:SUITE A
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401
Practice Address - Country:US
Practice Address - Phone:801-732-8200
Practice Address - Fax:801-732-8213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty