Provider Demographics
NPI:1891958963
Name:BROOME VISION INC.
Entity Type:Organization
Organization Name:BROOME VISION INC.
Other - Org Name:
Other - Org Type:
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 1:3781 S NOVA RD STE O
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-4285
Mailing Address - Country:US
Mailing Address - Phone:386-760-8626
Mailing Address - Fax:386-760-2676
Practice Address - Street 1:3781O S NOVA RD STE O
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-4233
Practice Address - Country:US
Practice Address - Phone:386-760-8626
Practice Address - Fax:386-760-2676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-08
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
FL000206403Medicaid
FL000206403Medicaid
FLAL995Medicare PIN
FL6253840002Medicare NSC