Provider Demographics
NPI:1689838393
Name:BROOME VISION INC
Entity Type:Organization
Organization Name:BROOME VISION INC
Other - Org Name:EYESAVERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-253-5999
Mailing Address - Street 1:1474 W GRANADA BLVD
Mailing Address - Street 2:STE 470
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9187
Mailing Address - Country:US
Mailing Address - Phone:386-673-3011
Mailing Address - Fax:
Practice Address - Street 1:1474 W GRANADA BLVD
Practice Address - Street 2:SUITE 470
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9187
Practice Address - Country:US
Practice Address - Phone:386-673-3011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-11
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000206402Medicaid
FL6253840001Medicare NSC