1912112756 NPI number — DR. JOHN SCHROLUCKE, OPTOMETRIST

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912112756 NPI number — DR. JOHN SCHROLUCKE, OPTOMETRIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. JOHN SCHROLUCKE, OPTOMETRIST
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912112756
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5140 W PEORIA AVE
Provider Second Line Business Mailing Address:
STE 116
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85302-1630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-487-1100
Provider Business Mailing Address Fax Number:
623-487-1417

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5140 W PEORIA AVE
Provider Second Line Business Practice Location Address:
STE 116
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85302-1630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-487-1100
Provider Business Practice Location Address Fax Number:
623-487-1417
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHROLUCKE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
623-487-1100

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  AZ212 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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