Provider Demographics
NPI:1699941393
Name:NICO ROUSE CORPORATION P S
Entity type:Organization
Organization Name:NICO ROUSE CORPORATION P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
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:
Mailing Address - Fax:
Practice Address - Street 1:8160 FREEDOM LN NE
Practice Address - Street 2:SUITE D
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4753
Practice Address - Country:US
Practice Address - Phone:360-790-1669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003743152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3183314OtherAETNA HMO
4536ROOtherREGENCE BLUE SHIELD
7283193OtherAETNA PPO
WAP00327511 DE9528OtherRAILROAD MEDICARE PART B
G8857648Medicare PIN
U72983Medicare UPIN
7283193OtherAETNA PPO