Provider Demographics
NPI:1912109398
Name:ROLLA OPTICAL
Entity Type:Organization
Organization Name:ROLLA OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IFEANYI
Authorized Official - Middle Name:S
Authorized Official - Last Name:ORIZU
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:573-364-5600
Mailing Address - Street 1:720 S BISHOP AVE
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 S BISHOP AVE
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-4317
Practice Address - Country:US
Practice Address - Phone:573-364-5600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO4710340001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4710340001Medicare NSC