1093805004 NPI number — EYEMART EXPRESS LTD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093805004 NPI number — EYEMART EXPRESS LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYEMART EXPRESS LTD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093805004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2110 HUTTON DR
Provider Second Line Business Mailing Address:
#100
Provider Business Mailing Address City Name:
CARROLLTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-488-2002
Provider Business Mailing Address Fax Number:
972-488-8563

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4415 AMBASSADOR CAFFERY PKWY
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70508-6705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
337-406-0620
Provider Business Practice Location Address Fax Number:
337-406-0667
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMUELSON
Authorized Official First Name:
MARY JO
Authorized Official Middle Name:
Authorized Official Title or Position:
CAO
Authorized Official Telephone Number:
972-488-2002

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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