Provider Demographics
NPI:1386851814
Name:DR. JOHN SCHROLUCKE, OPTOMETRIST
Entity Type:Organization
Organization Name:DR. JOHN SCHROLUCKE, OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHROLUCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-684-2880
Mailing Address - Street 1:25 W YAVAPAI ST
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-3280
Mailing Address - Country:US
Mailing Address - Phone:928-684-2880
Mailing Address - Fax:928-684-3209
Practice Address - Street 1:25 W YAVAPAI ST
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-3280
Practice Address - Country:US
Practice Address - Phone:928-684-2880
Practice Address - Fax:928-684-3209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ212152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZOD212Medicare PIN
AZ0747580002Medicare NSC
AZT76806Medicare UPIN