Provider Demographics
NPI:1861562340
Name:ROSEAU/WARROAD EYE CLINIC, P.A.
Entity type:Organization
Organization Name:ROSEAU/WARROAD EYE CLINIC, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:218-386-2081
Mailing Address - Street 1:BOX 446
Mailing Address - Street 2:301 LAKE STREET NE
Mailing Address - City:WARROAD
Mailing Address - State:MN
Mailing Address - Zip Code:56763
Mailing Address - Country:US
Mailing Address - Phone:218-386-2081
Mailing Address - Fax:218-386-1217
Practice Address - Street 1:301 LAKE STREET NE
Practice Address - Street 2:
Practice Address - City:WARROAD
Practice Address - State:MN
Practice Address - Zip Code:56763
Practice Address - Country:US
Practice Address - Phone:218-386-2081
Practice Address - Fax:218-386-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1618152W00000X
MN1693152W00000X
MN2946152W00000X
MN#1693152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN14000DIOtherBLUE CROSS BLUE SHIELD
MN14023EROtherBLUE CROSS BLUE SHIELD
MN275823700Medicaid
MN419000105Medicare PIN
MN14000DIOtherBLUE CROSS BLUE SHIELD
MN275823700Medicaid
MN419000104Medicare PIN