=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003010323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSSER OPT LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2007
-----------------------------------------------------
Last Update Date | 03/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 STRAWBERRY PLAINS RD STE B
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-220-2020
-----------------------------------------------------
Fax | 757-220-1340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 STRAWBERRY PLAINS RD STE B
-----------------------------------------------------
City | WILLIAMSBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23188-3408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-220-2020
-----------------------------------------------------
Fax | 757-220-1340
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN OWNER
-----------------------------------------------------
Name | WILLIE M ROSSER
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 757-220-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 1101000404
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | 1101000404
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------