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General NPI Number Information
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NPI Number | 1245504471
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Entity Type | Organization
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Legal Business Name | EXODUS VISION, LLC
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Dates
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Enumeration Date | 03/06/2012
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Last Update Date | 06/01/2012
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Provider Practice Location Address
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Address Line | 1260 LYELL AVE
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City | ROCHESTER
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State | NY
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Zip | 14606-2040
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Country | US
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Telephone | 585-254-0022
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Fax |
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Provider Business Mailing Address
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Address Line | 2580 ANTHEM VILLAGE DR
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City | HENDERSON
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State | NV
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Zip | 89052-5503
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Country | US
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Telephone | 585-254-0022
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Fax |
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Authorized Official
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Title or Position | ADMIN MANAGER
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Name | ERICA MARIE LIECHTY
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Credential |
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Telephone | 574-935-9827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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