Provider Demographics
NPI:1295915700
Name:BROADWAY VISION WORLD
Entity type:Organization
Organization Name:BROADWAY VISION WORLD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MASSIH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:503-223-6655
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97075-0108
Mailing Address - Country:US
Mailing Address - Phone:503-223-6655
Mailing Address - Fax:503-223-6657
Practice Address - Street 1:1962 SW BROADWAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-6710
Practice Address - Country:US
Practice Address - Phone:503-223-6655
Practice Address - Fax:503-233-6657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1863T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR013354Medicaid
OR13772Medicare UPIN