=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790949824
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R J ROWE OD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2008
-----------------------------------------------------
Last Update Date | 09/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 N MADISON ST
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31643-2012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-263-8851
-----------------------------------------------------
Fax | 229-263-7417
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 288
-----------------------------------------------------
City | QUITMAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31643-0288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-263-8851
-----------------------------------------------------
Fax | 229-263-7417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | RICKY J ROWE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 229-890-8016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 1026
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------