Provider Demographics
NPI:1215112776
Name:EYE-MART FACTORY OUTLET
Entity type:Organization
Organization Name:EYE-MART FACTORY OUTLET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-241-2884
Mailing Address - Street 1:2139 N 12TH ST
Mailing Address - Street 2:UNIT 5
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2901
Mailing Address - Country:US
Mailing Address - Phone:970-241-2020
Mailing Address - Fax:970-241-7735
Practice Address - Street 1:2139 N 12TH ST
Practice Address - Street 2:UNIT 5
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2901
Practice Address - Country:US
Practice Address - Phone:970-241-2020
Practice Address - Fax:970-241-7735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOTP125233AMedicaid
CO1160760001Medicare NSC