Provider Demographics
NPI:1093279275
Name:PIPER'S VISION XPRESS, LLC
Entity Type:Organization
Organization Name:PIPER'S VISION XPRESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-499-7715
Mailing Address - Street 1:50 PAUL WOOD LANE
Mailing Address - Street 2:
Mailing Address - City:MOUNTIAN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653
Mailing Address - Country:US
Mailing Address - Phone:870-492-2419
Mailing Address - Fax:870-492-2418
Practice Address - Street 1:50 PAUL WOOD LANE
Practice Address - Street 2:
Practice Address - City:MOUNTIAN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-492-2419
Practice Address - Fax:870-492-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-22
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1346358769Medicaid