Provider Demographics
NPI:1790999449
Name:ROCKY MOUNT OPTICIANS
Entity Type:Organization
Organization Name:ROCKY MOUNT OPTICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:WATSON
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:JR
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:252-443-6845
Mailing Address - Street 1:PO BOX 8496
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-1496
Mailing Address - Country:US
Mailing Address - Phone:252-443-6845
Mailing Address - Fax:
Practice Address - Street 1:3309 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-1496
Practice Address - Country:US
Practice Address - Phone:252-443-6845
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC263156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0201540001Medicare ID - Type Unspecified