Healthcare Provider Details

I. General information

NPI: 1750076022
Provider Name (Legal Business Name): AMANDA KAY BOSCOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/05/2025
Certification Date: 04/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 GREEN MOUNT COMMONS DR STE 290
BELLEVILLE IL
62221-6735
US

IV. Provider business mailing address

PO BOX 207163
DALLAS TX
75320-7163
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7800
  • Fax: 618-233-7290
Mailing address:
  • Phone: 636-200-4393
  • Fax: 636-527-0766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.011272
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: