Provider Demographics
NPI:1023182821
Name:NICO ROUSE CORPORATION PC
Entity Type:Organization
Organization Name:NICO ROUSE CORPORATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:FORREST
Authorized Official - Last Name:ROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-790-1669
Mailing Address - Street 1:9321 MILBURN LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-3420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5800 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:ELMENDORF AFB
Practice Address - State:AK
Practice Address - Zip Code:99506-1603
Practice Address - Country:US
Practice Address - Phone:907-753-7515
Practice Address - Fax:907-753-7585
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK226152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE9528OtherMEDICARE RAILROAD GROUP #
3183314OtherAETNA HMO
P00327511OtherMEDICARE RAILROAD
7283193OtherAETNA PPO
AKOD2260Medicaid
P00327511OtherMEDICARE RAILROAD
U72983Medicare UPIN
P00327511OtherMEDICARE RAILROAD
7283193OtherAETNA PPO