=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386703296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUCE J ROGERS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22 DEPOT ST MARKET SQURE MALL SUITE Z
-----------------------------------------------------
City | POTSDAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13676-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-265-2675
-----------------------------------------------------
Fax | 315-265-3899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22 DEPOT ST. MARKET SQURE MALL SUITE Z
-----------------------------------------------------
City | POTSDAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13676
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-265-2675
-----------------------------------------------------
Fax | 315-265-3899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTICIAN OWNER
-----------------------------------------------------
Name | MR. BRUCE J ROGERS
-----------------------------------------------------
Credential | OPTICIAN OWNER
-----------------------------------------------------
Telephone | 315-265-2675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | 0055651
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------