Provider Demographics
NPI:1134604267
Name:EYEMART EXPRESS LLC
Entity type:Organization
Organization Name:EYEMART EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RIMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-729-5300
Mailing Address - Street 1:1301 BOARDMAN POLAND RD STE J
Mailing Address - Street 2:
Mailing Address - City:POLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1960
Mailing Address - Country:US
Mailing Address - Phone:231-217-2167
Mailing Address - Fax:
Practice Address - Street 1:1301 BOARDMAN POLAND RD STE J
Practice Address - Street 2:
Practice Address - City:POLAND
Practice Address - State:OH
Practice Address - Zip Code:44514-1960
Practice Address - Country:US
Practice Address - Phone:231-217-2167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier