Healthcare Provider Details

I. General information

NPI: 1578613295
Provider Name (Legal Business Name): DRS. ROUSH & WILL OPTOMETRISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 E. NORTH ST
KENDALLVILLE IN
46755-1225
US

IV. Provider business mailing address

781 E. NORTH ST
KENDALLVILLE IN
46755-1225
US

V. Phone/Fax

Practice location:
  • Phone: 260-347-3611
  • Fax: 260-347-4425
Mailing address:
  • Phone: 260-347-3611
  • Fax: 260-347-4425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0921390001
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. R ALAN ROUSH
Title or Position: PRESIDENT
Credential: O.D.
Phone: 260-347-3611