Provider Demographics
NPI:1669873857
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 1:4614 SW LOOP 820
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4418
Mailing Address - Country:US
Mailing Address - Phone:817-732-2706
Mailing Address - Fax:972-277-3176
Practice Address - Street 1:4614 SW LOOP 820
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4418
Practice Address - Country:US
Practice Address - Phone:817-732-2706
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:2014-09-08
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier