Healthcare Provider Details

I. General information

NPI: 1659924207
Provider Name (Legal Business Name): LAUREN M ROVERSE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 JACKIE RD SE
RIO RANCHO NM
87124-6610
US

IV. Provider business mailing address

4025 JACKIE RD SE
RIO RANCHO NM
87124-6610
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-8411
  • Fax: 505-891-5497
Mailing address:
  • Phone: 505-892-8411
  • Fax: 505-891-5497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT2711
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: