Provider Demographics
NPI:1033204136
Name:R. SCOTT OBERBRECKLING, O.D. LLC
Entity Type:Organization
Organization Name:R. SCOTT OBERBRECKLING, O.D. LLC
Other - Org Name:BROADWAY EYE & VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:OBERBRECKLING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:303-938-8646
Mailing Address - Street 1:2648 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-3542
Mailing Address - Country:US
Mailing Address - Phone:303-938-8646
Mailing Address - Fax:303-938-4087
Practice Address - Street 1:2648 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3542
Practice Address - Country:US
Practice Address - Phone:303-938-8646
Practice Address - Fax:303-938-4087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO1975152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty