Provider Demographics
NPI:1730451279
Name:DRS. ROUSH & WILL OPTOMETRISTS INC
Entity type:Organization
Organization Name:DRS. ROUSH & WILL OPTOMETRISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-347-3458
Mailing Address - Street 1:117 W RUSH ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1739
Mailing Address - Country:US
Mailing Address - Phone:260-347-3458
Mailing Address - Fax:260-347-4425
Practice Address - Street 1:815 TRAIL RIDGE RD
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:IN
Practice Address - Zip Code:46701-1534
Practice Address - Country:US
Practice Address - Phone:260-636-7788
Practice Address - Fax:260-636-3463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100355140BMedicaid
IN967880OtherMEDICARE PTAN
IN100355140AMedicaid
IN100355140CMedicaid