=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417355595
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYEMART EXPRESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2014
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4206 KEMP BLVD
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76308-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-691-2020
-----------------------------------------------------
Fax | 940-691-2044
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4206 KEMP BLVD
-----------------------------------------------------
City | WICHITA FALLS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76308-2845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-691-2020
-----------------------------------------------------
Fax | 940-691-2044
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF MANAGED CARE
-----------------------------------------------------
Name | KAREN PITTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-488-2002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------