Provider Demographics
NPI:1386092039
Name:EYEMART EXPRESS LLC
Entity type:Organization
Organization Name:EYEMART EXPRESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CARUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-792-8136
Mailing Address - Street 1:1370 SOUTH COMMONS DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588
Mailing Address - Country:US
Mailing Address - Phone:843-353-6751
Mailing Address - Fax:972-277-3145
Practice Address - Street 1:1370 SOUTH COMMONS DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588
Practice Address - Country:US
Practice Address - Phone:843-353-6751
Practice Address - Fax:972-277-3145
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYEMART EXPRESS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier