Provider Demographics
NPI:1164165999
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:KARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-660-1993
Mailing Address - Street 1:1379 BOARDMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202
Mailing Address - Country:US
Mailing Address - Phone:517-879-4068
Mailing Address - Fax:517-879-5792
Practice Address - Street 1:1379 BOARDMAN ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202
Practice Address - Country:US
Practice Address - Phone:517-879-4068
Practice Address - Fax:517-879-5792
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-19
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier