Provider Demographics
NPI:1558031666
Name:ICO, AMANDA ROSE (OD)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ROSE
Last Name:ICO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 DELACOURTE AVE
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5007
Mailing Address - Country:US
Mailing Address - Phone:630-632-1208
Mailing Address - Fax:
Practice Address - Street 1:3143 SE MILITARY DR STE 131
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3988
Practice Address - Country:US
Practice Address - Phone:210-507-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10423T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist