Basic Information
Provider Information | |||||||||
NPI: | 1013048529 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WAL-MART STORES EAST, L.P. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VISION CENTER 30-5295 | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 702 SW 8TH STREET | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 727160235 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792779373 | ||||||||
FaxNumber: | 4792778176 | ||||||||
Practice Location | |||||||||
Address1: | 965 BROADHOLLOW RD | ||||||||
Address2: |   | ||||||||
City: | FARMINGDALE | ||||||||
State: | NY | ||||||||
PostalCode: | 11735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6316943520 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2007 | ||||||||
LastUpdateDate: | 09/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GUNDBERG | ||||||||
AuthorizedOfficialFirstName: | CORY | ||||||||
AuthorizedOfficialMiddleName: | JON | ||||||||
AuthorizedOfficialTitleorPosition: | SVP HEALTH & WELLNESS | ||||||||
AuthorizedOfficialTelephone: | 4792779621 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   |   | N |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   | 156FX1800X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.