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General NPI Number Information
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NPI Number | 1790999449
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Entity Type | Organization
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Legal Business Name | ROCKY MOUNT OPTICIANS
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3309 SUNSET AVE
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City | ROCKY MOUNT
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State | NC
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Zip | 27804-1496
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Country | US
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Telephone | 252-443-6845
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8496
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City | ROCKY MOUNT
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State | NC
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Zip | 27804-1496
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Country | US
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Telephone | 252-443-6845
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RALPH WATSON WALLACE JR.
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Credential | OPTICIAN
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Telephone | 252-443-6845
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 263
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License Number State | NC
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