Provider Demographics
NPI:1851583538
Name:BROADWAY MEDICAL SERVICE & SUPPLY, INC
Entity Type:Organization
Organization Name:BROADWAY MEDICAL SERVICE & SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:BIASCA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-442-3719
Mailing Address - Street 1:1034 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-0126
Mailing Address - Country:US
Mailing Address - Phone:707-442-3719
Mailing Address - Fax:707-442-0237
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-1925
Practice Address - Country:US
Practice Address - Phone:707-725-6944
Practice Address - Fax:707-725-1655
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DARR-B CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-15
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100211332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADME03117FMedicaid
CADME03117FMedicaid