Basic Information
| Provider Information | |||||||||
| NPI: | 1003804667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANSEN | ||||||||
| FirstName: | ROCKY | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488381759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167547143 | ||||||||
| FaxNumber: | 6167542778 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 S FRANKLIN | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488381905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167547143 | ||||||||
| FaxNumber: | 6167542778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 02/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4901002646 | MI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | RH002646 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 01256 | 01 | MI | PRIORITY HEALTH | OTHER | 943153415 | 05 | MI | MEDICAID |