Provider Demographics
NPI:1538567680
Name:EYEMART EXPRESS LLC
Entity type:Organization
Organization Name:EYEMART EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-488-2002
Mailing Address - Street 1:4302 13TH AVE S
Mailing Address - Street 2:STE. 6
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3395
Mailing Address - Country:US
Mailing Address - Phone:701-282-8007
Mailing Address - Fax:701-282-4973
Practice Address - Street 1:4302 13TH AVE S
Practice Address - Street 2:STE. 6
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3395
Practice Address - Country:US
Practice Address - Phone:701-282-8007
Practice Address - Fax:701-282-4973
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier