Provider Demographics
NPI:1609848878
Name:BROADLAWNS MEDICAL CENTER
Entity Type:Organization
Organization Name:BROADLAWNS MEDICAL CENTER
Other - Org Name:BROADLAWNS MEDICAL CENTER DENTAL CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANDRACCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:515-282-2562
Mailing Address - Street 1:1801 HICKMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-1505
Mailing Address - Country:US
Mailing Address - Phone:515-282-2421
Mailing Address - Fax:
Practice Address - Street 1:1801 HICKMAN RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-1505
Practice Address - Country:US
Practice Address - Phone:515-282-2421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07724122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0066068Medicaid
IA2601013OtherIOWA CARE
IA20023OtherTRICARE
IA6230290OtherAETNA
IAA5031401OtherJOHN DEERE UHC RIVER VALL
IA29705OtherCOVENTRY
IAA5031401OtherJOHN DEERE UHC RIVER VALL
IA6230290OtherAETNA