Basic Information
Provider Information
NPI: 1003804667
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HANSEN
FirstName: ROCKY
MiddleName: G
NamePrefix: DR.
NameSuffix:  
Credential: OD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 02/07/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X4901002646MIY Eye and Vision Services ProvidersOptometrist 

ID Information
IDTypeStateIssuerDescription
94315341505MI MEDICAID
RH00264601MIBLUE CROSS BLUE SHIELDOTHER
0125601MIPRIORITY HEALTHOTHER


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