Provider Demographics
NPI:1053039370
Name:SEYBOLDT, ALAN (OPTICIAN)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:SEYBOLDT
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E 3300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2849
Mailing Address - Country:US
Mailing Address - Phone:801-466-3937
Mailing Address - Fax:
Practice Address - Street 1:1025 E 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2849
Practice Address - Country:US
Practice Address - Phone:801-466-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician