Provider Demographics
NPI:1841740503
Name:KING AND ROSE OPTICAL, INC.
Entity Type:Organization
Organization Name:KING AND ROSE OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVOST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:737-484-1512
Mailing Address - Street 1:6701 BURNET RD
Mailing Address - Street 2:SUITE C2
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6701 BURNET RD
Practice Address - Street 2:SUITE C2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-2855
Practice Address - Country:US
Practice Address - Phone:737-484-1512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7799-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty