Healthcare Provider Details

I. General information

NPI: 1669875514
Provider Name (Legal Business Name): ROSEAU WARROAD EYE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 10/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAKE STREET
WARROAD MN
56763
US

IV. Provider business mailing address

306 MAIN AVE N
ROSEAU MN
56751-1820
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-2081
  • Fax:
Mailing address:
  • Phone: 218-463-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ROSS OLSON
Title or Position: OWNER/OPTOMETRIST
Credential: OD
Phone: 218-463-2020