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General NPI Number Information
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NPI Number | 1558466912
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Entity Type | Organization
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Legal Business Name | ROGER W FITCH OD
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 11/09/2010
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Provider Practice Location Address
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Address Line | 4900 N GLEN PARK PLACE RD SUITE C
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City | PEORIA
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State | IL
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Zip | 61614-4679
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Country | US
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Telephone | 309-691-4500
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Fax | 309-693-2534
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Provider Business Mailing Address
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Address Line | 4900 N GLEN PARK PLACE RD SUITE C
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City | PEORIA
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State | IL
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Zip | 61614-4679
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Country | US
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Telephone | 309-691-4500
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Fax | 309-693-2534
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Authorized Official
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Title or Position | OWNER
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Name | DR. ROGER W FITCH
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Credential | O.D.
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Telephone | 309-691-4500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046006836
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License Number State | IL
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