Provider Demographics
NPI:1902968837
Name:ROSEDALE EYECARE
Entity Type:Organization
Organization Name:ROSEDALE EYECARE
Other - Org Name:ROSEDALE EYECARE LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-533-4003
Mailing Address - Street 1:19460 GRAND RIVER
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223
Mailing Address - Country:US
Mailing Address - Phone:313-533-4003
Mailing Address - Fax:
Practice Address - Street 1:19460 GRAND RIVER
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223
Practice Address - Country:US
Practice Address - Phone:313-533-4003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
MI4901002131332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4J10880Medicaid
MI4J10880Medicaid
T81442Medicare UPIN