Healthcare Provider Details

I. General information

NPI: 1750720702
Provider Name (Legal Business Name): VALARIE ROACHE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6233 CERMAK RD
BERWYN IL
60402-2317
US

IV. Provider business mailing address

7180 DEXTER RD
DOWNERS GROVE IL
60516-3709
US

V. Phone/Fax

Practice location:
  • Phone: 708-749-2020
  • Fax:
Mailing address:
  • Phone: 630-212-3538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046.010642
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: