Provider Demographics
NPI:1629542600
Name:EYEMART EXPRESS LLC
Entity Type:Organization
Organization Name:EYEMART EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RIMMA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-729-5300
Mailing Address - Street 1:4542 ELKHART RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46517-3572
Mailing Address - Country:US
Mailing Address - Phone:574-538-4236
Mailing Address - Fax:
Practice Address - Street 1:4542 ELKHART RD STE 100
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-3572
Practice Address - Country:US
Practice Address - Phone:574-538-4236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier