Provider Demographics
NPI:1902209695
Name:20-20 EXPRESS--DALLAS LLC
Entity Type:Organization
Organization Name:20-20 EXPRESS--DALLAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-997-1583
Mailing Address - Street 1:2469 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-9430
Mailing Address - Country:US
Mailing Address - Phone:469-362-8625
Mailing Address - Fax:972-277-3176
Practice Address - Street 1:2469 PRESTON RD
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-9430
Practice Address - Country:US
Practice Address - Phone:469-362-8625
Practice Address - Fax:972-277-3176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:20-20 EXPRESS--DALLAS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier