MEDICARE: EYEMART EXPRESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier

General Provider Information

NPI Number	:	1487162061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEMART EXPRESS LLC

Provider Business Mailing Address
First Line	:	3201 MONTGOMERY HWY STE 1
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-2113
Country	:	US
Telephone Number	:	334-350-5315
Fax Number	:	972-277-3176

Provider Business Practice Location Address
First Line	:	3201 MONTGOMERY HWY STE 1
Second Line	:
City	:	DOTHAN
State	:	AL
Zip	:	36303-2113
Country	:	US
Telephone Number	:	334-350-5315
Fax Number	:	972-277-3176

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KIM CARUSO
Credential	:
Telephone Number	:	212-792-8136

Provider Enumeration Date	:	01/17/2018
Last Update Date	:	01/17/2018

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Directions to “EYEMART EXPRESS LLC ” Practice Location

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