Healthcare Provider Details

I. General information

NPI: 1386703296
Provider Name (Legal Business Name): BRUCE J ROGERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 DEPOT ST MARKET SQURE MALL SUITE Z
POTSDAM NY
13676-1140
US

IV. Provider business mailing address

22 DEPOT ST. MARKET SQURE MALL SUITE Z
POTSDAM NY
13676
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-2675
  • Fax: 315-265-3899
Mailing address:
  • Phone: 315-265-2675
  • Fax: 315-265-3899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0055651
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateNY

VIII. Authorized Official

Name: MR. BRUCE J ROGERS
Title or Position: OPTICIAN OWNER
Credential: OPTICIAN OWNER
Phone: 315-265-2675