MEDICARE: OPTICIANS OF GLEN ROCK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician	31TD00355800	NJ

General Provider Information

NPI Number	:	1063959856
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTICIANS OF GLEN ROCK

Provider Business Mailing Address
First Line	:	240 ROCK RD
Second Line	:	SUITE 1B
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1738
Country	:	US
Telephone Number	:	201-857-2620
Fax Number	:	201-857-2619

Provider Business Practice Location Address
First Line	:	240 ROCK RD
Second Line	:	SUITE 1B
City	:	GLEN ROCK
State	:	NJ
Zip	:	07452-1738
Country	:	US
Telephone Number	:	201-857-2620
Fax Number	:	201-857-2619

Authorized Official
Title or Position	:	CO-OWNER
Name	:	IRVING SAMORA
Credential	:
Telephone Number	:	201-857-2620

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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Directions to “OPTICIANS OF GLEN ROCK ” Practice Location

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