Provider Demographics
NPI:1992966204
Name:ROSE EYE CLINIC
Entity type:Organization
Organization Name:ROSE EYE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:SAMUEL
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:662-887-5668
Mailing Address - Street 1:401 CATCHINGS AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANOLA
Mailing Address - State:MS
Mailing Address - Zip Code:38751-2468
Mailing Address - Country:US
Mailing Address - Phone:662-887-5668
Mailing Address - Fax:662-887-5671
Practice Address - Street 1:401 CATCHINGS AVE
Practice Address - Street 2:
Practice Address - City:INDIANOLA
Practice Address - State:MS
Practice Address - Zip Code:38751-2468
Practice Address - Country:US
Practice Address - Phone:662-887-5668
Practice Address - Fax:662-887-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS571152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G700242Medicare PIN
MS6373010001Medicare NSC