Healthcare Provider Details

I. General information

NPI: 1902370257
Provider Name (Legal Business Name): EYEMART EXPRESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 01/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 WESTERN AVE
AUGUSTA ME
04330-4902
US

IV. Provider business mailing address

254 WESTERN AVE
AUGUSTA ME
04330-4902
US

V. Phone/Fax

Practice location:
  • Phone: 207-307-2780
  • Fax:
Mailing address:
  • Phone: 207-307-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: RIMMA LUSKIN
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 212-729-5300