MEDICARE: ROSE OPTICAL, INC.

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	22652655	IL

General Provider Information

NPI Number	:	1669444063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSE OPTICAL, INC.

Provider Business Mailing Address
First Line	:	PO BOX 5040
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-5040
Country	:	US
Telephone Number	:	618-466-8787
Fax Number	:	618-466-4703

Provider Business Practice Location Address
First Line	:	3300 GODFREY RD
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-2558
Country	:	US
Telephone Number	:	618-466-8787
Fax Number	:	618-466-4703

Authorized Official
Title or Position	:	BOARD SECRETARY/TREAS.
Name	:	MRS. MARIE ANNETTE MANGRUM
Credential	:
Telephone Number	:	618-466-8787

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	08/29/2011

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Directions to “ROSE OPTICAL, INC. ” Practice Location

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