Provider Demographics
NPI:1528065166
Name:ROGER'S WABASH OPTICAL, LLC
Entity type:Organization
Organization Name:ROGER'S WABASH OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-945-0440
Mailing Address - Street 1:612 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4734
Mailing Address - Country:US
Mailing Address - Phone:812-945-0440
Mailing Address - Fax:812-948-2020
Practice Address - Street 1:612 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4734
Practice Address - Country:US
Practice Address - Phone:812-945-0440
Practice Address - Fax:812-948-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN5303000001Medicare ID - Type Unspecified