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	:	1902691090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYEMART EXPRESS LLC

Provider Business Mailing Address
First Line	:	7307 NORTH CULTURE WAY
Second Line	:
City	:	COEUR D'ALENE
State	:	ID
Zip	:	83815
Country	:	US
Telephone Number	:	208-956-0017
Fax Number	:	208-956-0018

Provider Business Practice Location Address
First Line	:	7307 NORTH CULTURE WAY
Second Line	:
City	:	COEUR D'ALENE
State	:	ID
Zip	:	83815
Country	:	US
Telephone Number	:	208-956-0017
Fax Number	:	208-956-0018

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	KIM CARUSO
Credential	:
Telephone Number	:	646-660-1993

Provider Enumeration Date	:	04/10/2025
Last Update Date	:	04/10/2025

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