Provider Demographics
NPI:1205234267
Name:EYEMART EXPRESS LLC
Entity type:Organization
Organization Name:EYEMART EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-660-1993
Mailing Address - Street 1:2510 MAPLE GROVE RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1807
Mailing Address - Country:US
Mailing Address - Phone:218-722-2712
Mailing Address - Fax:218-722-2716
Practice Address - Street 1:2510 MAPLE GROVE RD
Practice Address - Street 2:SUITE 500
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-1807
Practice Address - Country:US
Practice Address - Phone:218-722-2712
Practice Address - Fax:218-722-2716
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-08
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier