Provider Demographics
NPI:1689789570
Name:ROSE VISION CARE LLC
Entity Type:Organization
Organization Name:ROSE VISION CARE LLC
Other - Org Name:VISION XPRESS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:TOD
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:417-256-8393
Mailing Address - Street 1:1713 GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1713 GIBSON ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-1815
Practice Address - Country:US
Practice Address - Phone:417-256-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001024885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO315902205Medicaid
MO315902205Medicaid
MO5280680001Medicare NSC
MOU 87118Medicare UPIN