Healthcare Provider Details

I. General information

NPI: 1871679456
Provider Name (Legal Business Name): ROSEAU/WARROAD EYE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N MAIN
ROSEAU MN
56751
US

IV. Provider business mailing address

306 N MAIN
ROSEAU MN
56751
US

V. Phone/Fax

Practice location:
  • Phone: 218-463-2020
  • Fax: 218-463-2055
Mailing address:
  • Phone: 218-463-2020
  • Fax: 218-463-2055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1618
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2946
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1693
License Number StateMN

VIII. Authorized Official

Name: MR. ROSS JAMES OLSON
Title or Position: OWNER/ OPTOMETRIST
Credential: O.D.
Phone: 218-463-2020