Healthcare Provider Details

I. General information

NPI: 1689855223
Provider Name (Legal Business Name): ROSCOE OPTOMETRIC CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2007
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W MAIN ST
SANFORD NC
27332-5924
US

IV. Provider business mailing address

PO BOX 3517
SANFORD NC
27331-3517
US

V. Phone/Fax

Practice location:
  • Phone: 919-776-2712
  • Fax: 919-775-3486
Mailing address:
  • Phone: 919-776-2712
  • Fax: 919-775-3486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0969
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0969
License Number StateNC

VIII. Authorized Official

Name: DR. WILLIAM DOUGLAS ROSCOE
Title or Position: OWNER/OPTOMETRIST
Credential: O.D.
Phone: 919-776-2712