Healthcare Provider Details

I. General information

NPI: 1508857202
Provider Name (Legal Business Name): CONSTANCE S COPELAND OD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8038 MACINTOSH LN
ROCKFORD IL
61107-5336
US

IV. Provider business mailing address

8038 MACINTOSH LN
ROCKFORD IL
61107-5336
US

V. Phone/Fax

Practice location:
  • Phone: 815-332-6800
  • Fax: 815-332-6810
Mailing address:
  • Phone: 815-332-6800
  • Fax: 815-332-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046011082
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: