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:
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Mailing Address - Street 1:368 GLENWOOD DR APT 304
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-3263
Mailing Address - Country:US
Mailing Address - Phone:630-632-1208
Mailing Address - Fax:
Practice Address - Street 1:6440 MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-1753
Practice Address - Country:US
Practice Address - Phone:630-232-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX10423T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist