Healthcare Provider Details

I. General information

NPI: 1982185559
Provider Name (Legal Business Name): EYEMART EXPRESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 N MAIN ST STE A
ROSWELL NM
88201-0309
US

IV. Provider business mailing address

4511 N MAIN ST STE A
ROSWELL NM
88201-0309
US

V. Phone/Fax

Practice location:
  • Phone: 575-912-1028
  • Fax:
Mailing address:
  • Phone: 575-912-1028
  • 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: KIM CARUSO
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 212-792-8136