Provider Demographics
NPI:1578613295
Name:DRS. ROUSH & WILL OPTOMETRISTS INC
Entity Type:Organization
Organization Name:DRS. ROUSH & WILL OPTOMETRISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-347-3611
Mailing Address - Street 1:781 E. NORTH ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1225
Mailing Address - Country:US
Mailing Address - Phone:260-347-3611
Mailing Address - Fax:260-347-4425
Practice Address - Street 1:781 E. NORTH ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1225
Practice Address - Country:US
Practice Address - Phone:260-347-3611
Practice Address - Fax:260-347-4425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IN0921390001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100355140BMedicaid
IN100355140CMedicaid
IN100355140AMedicaid
IN100355140CMedicaid
IN0921390001Medicare NSC