Provider Demographics
NPI:1912112756
Name:DR. JOHN SCHROLUCKE, OPTOMETRIST
Entity Type:Organization
Organization Name:DR. JOHN SCHROLUCKE, OPTOMETRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHROLUCKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:623-487-1100
Mailing Address - Street 1:5140 W PEORIA AVE
Mailing Address - Street 2:STE 116
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-1630
Mailing Address - Country:US
Mailing Address - Phone:623-487-1100
Mailing Address - Fax:623-487-1417
Practice Address - Street 1:5140 W PEORIA AVE
Practice Address - Street 2:STE 116
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-1630
Practice Address - Country:US
Practice Address - Phone:623-487-1100
Practice Address - Fax:623-487-1417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
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
0747580001Medicare NSC