Provider Demographics
NPI:1629256730
Name:BROADWAY VISION CENTER
Entity Type:Organization
Organization Name:BROADWAY VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVI
Authorized Official - Middle Name:HANNELE
Authorized Official - Last Name:LEYENDECKERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-222-6888
Mailing Address - Street 1:926 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2730
Mailing Address - Country:US
Mailing Address - Phone:217-222-6888
Mailing Address - Fax:217-222-6975
Practice Address - Street 1:926 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2730
Practice Address - Country:US
Practice Address - Phone:217-222-6888
Practice Address - Fax:217-222-6975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046008462332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1083711642OtherNPI
1128930001Medicare NSC