Healthcare Provider Details

I. General information

NPI: 1861562340
Provider Name (Legal Business Name): ROSEAU/WARROAD EYE CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 LAKE STREET NE
WARROAD MN
56763
US

IV. Provider business mailing address

BOX 446 301 LAKE STREET NE
WARROAD MN
56763
US

V. Phone/Fax

Practice location:
  • Phone: 218-386-2081
  • Fax: 218-386-1217
Mailing address:
  • Phone: 218-386-2081
  • Fax: 218-386-1217

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 Number1693
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2946
License Number StateMN
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number#1693
License Number StateMN

VIII. Authorized Official

Name: MR. ROSS JAMES OLSON
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 218-386-2081