MEDICARE: RANDALL R RICKETTS O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	047.932299	IL

General Provider Information

NPI Number	:	1083823611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL R RICKETTS O.D.

Provider Business Mailing Address
First Line	:	1133 W PRATT BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4403
Country	:	US
Telephone Number	:	773-510-2769
Fax Number	:

Provider Business Practice Location Address
First Line	:	1953 N CLYBOURN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4945
Country	:	US
Telephone Number	:	773-857-1260
Fax Number	:	773-857-1624

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	08/14/2015

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