Provider Demographics
NPI:1992937338
Name:ROSEVILLE OPTICIANS
Entity type:Organization
Organization Name:ROSEVILLE OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:651-489-8800
Mailing Address - Street 1:1790 LEXINGTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-6167
Mailing Address - Country:US
Mailing Address - Phone:651-489-8800
Mailing Address - Fax:
Practice Address - Street 1:1790 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-6167
Practice Address - Country:US
Practice Address - Phone:651-489-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEDY EYE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN27620ROOtherBC/BS OF MN