Provider Demographics
NPI:1609258581
Name:AVA ROSE EYECARE LTD
Entity Type:Organization
Organization Name:AVA ROSE EYECARE LTD
Other - Org Name:PRECISION FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DIECKOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:314-599-1034
Mailing Address - Street 1:1115 N HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2523
Mailing Address - Country:US
Mailing Address - Phone:309-343-1107
Mailing Address - Fax:309-343-1306
Practice Address - Street 1:1115 N HENDERSON ST
Practice Address - Street 2:
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2523
Practice Address - Country:US
Practice Address - Phone:309-343-1107
Practice Address - Fax:309-343-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty