Provider Demographics
NPI:1417143728
Name:NICO ROUSE CORPORATION
Entity type:Organization
Organization Name:NICO ROUSE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-790-1669
Mailing Address - Street 1:9321 MILBURN LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-3420
Mailing Address - Country:US
Mailing Address - Phone:360-790-1669
Mailing Address - Fax:360-456-1545
Practice Address - Street 1:2202 LIGGETT AVENUE
Practice Address - Street 2:
Practice Address - City:FORT LEWIS
Practice Address - State:WA
Practice Address - Zip Code:98433-9500
Practice Address - Country:US
Practice Address - Phone:253-964-4140
Practice Address - Fax:253-964-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003743152W00000X
WAOD00004138152W00000X
WAOD00003984152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4536ROOtherREGENCE BLUE SHIELD
3183314OtherAETNA HMO
7283193OtherAETNA PPO
WAP00327511 DE9528OtherMEDICARE RAIL ROAD
WA=========OtherTRICARE PIN#
7283193OtherAETNA PPO
3183314OtherAETNA HMO
U72983Medicare UPIN