Healthcare Provider Details

I. General information

NPI: 1245433705
Provider Name (Legal Business Name): BETSY A ROSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 06/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 CUMMINGS ST
ABINGDON VA
24210-3207
US

IV. Provider business mailing address

329 CUMMINGS ST
ABINGDON VA
24210-3207
US

V. Phone/Fax

Practice location:
  • Phone: 276-628-9970
  • Fax: 276-628-9937
Mailing address:
  • Phone: 276-628-9970
  • Fax: 276-628-9937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1101001369
License Number StateVA

VIII. Authorized Official

Name: MS. BETSY A. ROSE
Title or Position: OFFICE MANAGER/OWNER
Credential:
Phone: 276-628-9970