Provider Demographics
NPI:1710456249
Name:BROADWAY VISION SOURCE, INCORPORATED
Entity Type:Organization
Organization Name:BROADWAY VISION SOURCE, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:515-448-3813
Mailing Address - Street 1:300 W BROADWAY ST
Mailing Address - Street 2:P.O BOX 459
Mailing Address - City:EAGLE GROVE
Mailing Address - State:IA
Mailing Address - Zip Code:50533-1712
Mailing Address - Country:US
Mailing Address - Phone:515-448-3813
Mailing Address - Fax:515-448-3885
Practice Address - Street 1:300 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EAGLE GROVE
Practice Address - State:IA
Practice Address - Zip Code:50533-1712
Practice Address - Country:US
Practice Address - Phone:515-448-3813
Practice Address - Fax:515-448-3885
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROADWAY VISION SOURCE, INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1346620432OtherINDIVIDUAL NPI
IA1346620432Medicaid