Provider Demographics
NPI:1093113078
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 1:2515 N PROSPECT AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1226
Mailing Address - Country:US
Mailing Address - Phone:217-355-0354
Mailing Address - Fax:217-355-0722
Practice Address - Street 1:2515 N PROSPECT AVE
Practice Address - Street 2:STE 100
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-1226
Practice Address - Country:US
Practice Address - Phone:217-355-0354
Practice Address - Fax:217-355-0722
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