=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750663787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEVILLE OPTOMETRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2011
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 576 N SUNRISE AVE STE. 110
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-773-3937
-----------------------------------------------------
Fax | 916-773-3936
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 576 N SUNRISE AVE STE. 110
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95661-2841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-773-3937
-----------------------------------------------------
Fax | 916-773-3936
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OPTOMETRIST
-----------------------------------------------------
Name | CHRISTINE NGUYEN SNOW
-----------------------------------------------------
Credential | O.D
-----------------------------------------------------
Telephone | 916-773-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 13273
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------