Provider Demographics
NPI:1922278704
Name:BROOME VISION INC
Entity Type:Organization
Organization Name:BROOME VISION INC
Other - Org Name:DAYTONA EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-253-5999
Mailing Address - Street 1:PO BOX 351
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32115-0351
Mailing Address - Country:US
Mailing Address - Phone:386-253-5999
Mailing Address - Fax:386-253-1193
Practice Address - Street 1:701 S RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5331
Practice Address - Country:US
Practice Address - Phone:386-253-5999
Practice Address - Fax:386-253-1193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3301152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000206400Medicaid
6253840003Medicare UPIN
FL000206400Medicaid
FL6253840003Medicare NSC
FLDN8893Medicare PIN