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NPI Code Detail

MEDICARE: GLENN K. ROTER, OD, A PROFESSIONAL CORPORATION

MEDICARE: GLENN K. ROTER, OD, A PROFESSIONAL CORPORATION
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
1152W00000XOptometristNV 411NV

General Provider Information

NPI Number : 1053612424
Entity Type Code : Organization
Provider Name (Legal Business Name) : GLENN K. ROTER, OD, A PROFESSIONAL CORPORATION
Provider Business Mailing Address
First Line : 5200 S FORT APACHE RD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-1722
Country : US
Telephone Number : 702-368-0092
Fax Number : 702-368-0097
Provider Business Practice Location Address
First Line : 5200 S FORT APACHE RD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-1722
Country : US
Telephone Number : 702-368-0092
Fax Number : 702-368-0097
Authorized Official
Title or Position : PRESIDENT
Name : DR. GLENN K. ROTER
Credential : O.D.
Telephone Number : 702-368-0092
Provider Enumeration Date : 11/16/2010
Last Update Date : 11/16/2010

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