Provider Demographics
NPI:1740362524
Name:HAROLD ROSE OD
Entity type:Organization
Organization Name:HAROLD ROSE OD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-523-9801
Mailing Address - Street 1:2819 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25702-1435
Mailing Address - Country:US
Mailing Address - Phone:304-523-9801
Mailing Address - Fax:304-522-4651
Practice Address - Street 1:2819 5TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1435
Practice Address - Country:US
Practice Address - Phone:304-523-9801
Practice Address - Fax:304-522-4651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV480-D152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149604000Medicaid
9137752Medicare PIN
WVCM5416Medicare PIN