Provider Demographics
NPI:1417105347
Name:BROAD STREET FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:BROAD STREET FAMILY HEALTH CENTER
Other - Org Name:SPSI - BROAD STREET FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:9276 SCRANTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-7701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:211 BROAD ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17053-1302
Practice Address - Country:US
Practice Address - Phone:717-957-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS010593L332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site