MEDICARE: BRUNSWICK OPTICAL

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

General Provider Information

NPI Number	:	1659920189
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUNSWICK OPTICAL

Provider Business Mailing Address
First Line	:	1486 WATERBURY RD
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-4817
Country	:	US
Telephone Number	:	216-571-0726
Fax Number	:

Provider Business Practice Location Address
First Line	:	1333 N CARPENTER RD
Second Line	:
City	:	BRUNSWICK
State	:	OH
Zip	:	44212-3178
Country	:	US
Telephone Number	:	330-741-3407
Fax Number	:	330-741-4037

Authorized Official
Title or Position	:	OWNER
Name	:	MATTHEW GRUCELLA
Credential	:
Telephone Number	:	216-571-0726

Provider Enumeration Date	:	09/07/2019
Last Update Date	:	09/08/2019

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Directions to “BRUNSWICK OPTICAL ” Practice Location

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