Basic Information
| Provider Information | |||||||||
| NPI: | 1619341575 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | ELENA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 208177 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753208177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6362004393 | ||||||||
| FaxNumber: | 6365270766 | ||||||||
| Practice Location | |||||||||
| Address1: | 22350 NOVI RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483754708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483477800 | ||||||||
| FaxNumber: | 2483477801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2015 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152WC0802X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152WL0500X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Low Vision Rehabilitation | 152WP0200X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Pediatrics | 152WS0006X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Sports Vision | 152WV0400X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Vision Therapy | 152WX0102X | 4901004945 | MI | N | Eye and Vision Services Providers | Optometrist | Occupational Vision | 152W00000X | 4901004945 | MI | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.