Provider Demographics
NPI:1932191954
Name:ROSE, J LANCASTER JR
Entity Type:Individual
Prefix:
First Name:J
Middle Name:LANCASTER
Last Name:ROSE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37091-3351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 CEDAR ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:TN
Practice Address - Zip Code:37091-3351
Practice Address - Country:US
Practice Address - Phone:931-359-1467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000001122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0077625OtherBCBS
TN3596313Medicaid
TN3596313Medicaid
TN0866790001Medicare NSC
TN3596313Medicare PIN