Healthcare Provider Details

I. General information

NPI: 1699173674
Provider Name (Legal Business Name): EYEMART EXPRESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9935 COORS BYP NW STE B
ALBUQUERQUE NM
87114-6195
US

IV. Provider business mailing address

9935 COORS BYP NW STE B
ALBUQUERQUE NM
87114-6195
US

V. Phone/Fax

Practice location:
  • Phone: 505-922-9000
  • Fax: 505-922-9010
Mailing address:
  • Phone: 505-922-9000
  • Fax: 505-922-9010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KAREN PITTMAN
Title or Position: DIRECTOR OF MANAGED CARE
Credential:
Phone: 972-488-2002