Basic Information
| Provider Information | |||||||||
| NPI: | 1043392483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAL-MART STORES EAST, LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WAL-MART VISION CENTER 30-1209 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727160445 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792771238 | ||||||||
| FaxNumber: | 4792774331 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 N GENERALS BLVD | ||||||||
| Address2: | |||||||||
| City: | LINCOLNTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7047320917 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/28/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAINTER | ||||||||
| AuthorizedOfficialFirstName: | DIANNA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4792771238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAL-MART STORES INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.