Healthcare Provider Details

I. General information

NPI: 1386851814
Provider Name (Legal Business Name): DR. JOHN SCHROLUCKE, OPTOMETRIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 W YAVAPAI ST
WICKENBURG AZ
85390-3280
US

IV. Provider business mailing address

25 W YAVAPAI ST
WICKENBURG AZ
85390-3280
US

V. Phone/Fax

Practice location:
  • Phone: 928-684-2880
  • Fax: 928-684-3209
Mailing address:
  • Phone: 928-684-2880
  • Fax: 928-684-3209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberAZ212
License Number StateAZ

VIII. Authorized Official

Name: MRS. CATHY SCHROLUCKE
Title or Position: OFFICE MANAGER
Credential:
Phone: 928-684-2880