Provider Demographics
NPI:1659924207
Name:ROVERSE, LAUREN M (OD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:ROVERSE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 JACKIE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6610
Mailing Address - Country:US
Mailing Address - Phone:505-892-8411
Mailing Address - Fax:505-891-5497
Practice Address - Street 1:4025 JACKIE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6610
Practice Address - Country:US
Practice Address - Phone:505-892-8411
Practice Address - Fax:505-891-5497
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOPT2711152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist