Basic Information
| Provider Information | |||||||||
| NPI: | 1992364020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 891 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013317850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 POUND HILL RD STE 104 | ||||||||
| Address2: | |||||||||
| City: | NORTH SMITHFIELD | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028969358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017696323 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2019 | ||||||||
| LastUpdateDate: | 05/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODTG00679 | RI | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | BC00404662 | 01 | RI | BLUE CROSS BLUE SHIELD OF RI | OTHER |