MEDICARE: CLASIK VISION CARE PLLC

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	152W00000X	Optometrist	791	AZ

General Provider Information

NPI Number	:	1144567173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLASIK VISION CARE PLLC

Provider Business Mailing Address
First Line	:	3125 W HUNT HWY # B-102
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85142-9315
Country	:	US
Telephone Number	:	480-525-2025
Fax Number	:	480-422-8749

Provider Business Practice Location Address
First Line	:	3125 W HUNT HWY # B-102
Second Line	:
City	:	SAN TAN VALLEY
State	:	AZ
Zip	:	85142-9315
Country	:	US
Telephone Number	:	480-525-2025
Fax Number	:	480-422-8749

Authorized Official
Title or Position	:	DOCTOR/OWNER
Name	:	DR. JORDAN D ROTHLISBERGER
Credential	:	OD
Telephone Number	:	480-861-0590

Provider Enumeration Date	:	01/10/2013
Last Update Date	:	01/03/2019

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