Provider Demographics
NPI:1043737737
Name:EYECARE EXPRESS
Entity Type:Organization
Organization Name:EYECARE EXPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN/DOCTOR TECH
Authorized Official - Prefix:MISS
Authorized Official - First Name:SHAWNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-482-2020
Mailing Address - Street 1:4826 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1166
Mailing Address - Country:US
Mailing Address - Phone:260-434-2021
Mailing Address - Fax:260-459-6331
Practice Address - Street 1:4826 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1166
Practice Address - Country:US
Practice Address - Phone:260-434-2021
Practice Address - Fax:260-459-6331
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYECARE EXPRESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty