Provider Demographics
NPI:1780719807
Name:BROADWAY VISION SOURCE
Entity type:Organization
Organization Name:BROADWAY VISION SOURCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MATSUNAMI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:206-464-0742
Mailing Address - Street 1:BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122
Mailing Address - Country:US
Mailing Address - Phone:206-464-0472
Mailing Address - Fax:206-464-0572
Practice Address - Street 1:BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3609
Practice Address - Country:US
Practice Address - Phone:206-464-0472
Practice Address - Fax:206-464-0572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center