Provider Demographics
NPI:1669444063
Name:ROSE OPTICAL, INC.
Entity Type:Organization
Organization Name:ROSE OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD SECRETARY/TREAS.
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:MANGRUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-466-8787
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-5040
Mailing Address - Country:US
Mailing Address - Phone:618-466-8787
Mailing Address - Fax:618-466-4703
Practice Address - Street 1:3300 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2558
Practice Address - Country:US
Practice Address - Phone:618-466-8787
Practice Address - Fax:618-466-4703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL22652655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0728570001Medicare NSC
IL216190Medicare PIN
ILDQ8668Medicare PIN