Provider Demographics
NPI:1568641439
Name:DANIEL L. GAUERKEI DBA BROADWAY VISION CENTER
Entity Type:Organization
Organization Name:DANIEL L. GAUERKEI DBA BROADWAY VISION CENTER
Other - Org Name:BROADWAY VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HEIDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-258-9122
Mailing Address - Street 1:815 W FULTON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-1405
Mailing Address - Country:US
Mailing Address - Phone:715-258-9122
Mailing Address - Fax:715-258-3090
Practice Address - Street 1:815 W FULTON ST
Practice Address - Street 2:SUITE 103
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1405
Practice Address - Country:US
Practice Address - Phone:715-258-9122
Practice Address - Fax:715-258-3090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1938261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0469210001Medicare NSC
WI000047285Medicare PIN