Provider Demographics
NPI:1245504471
Name:EXODUS VISION, LLC
Entity type:Organization
Organization Name:EXODUS VISION, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LIECHTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-935-9827
Mailing Address - Street 1:2580 ANTHEM VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-5503
Mailing Address - Country:US
Mailing Address - Phone:585-254-0022
Mailing Address - Fax:
Practice Address - Street 1:1260 LYELL AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14606-2040
Practice Address - Country:US
Practice Address - Phone:585-254-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier