MEDICARE: NICOLE M BROADWELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1235966458
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE M BROADWELL

Provider Business Mailing Address
First Line	:	3018 EAST AVE
Second Line	:
City	:	CENTRAL SQUARE
State	:	NY
Zip	:	13036-2713
Country	:	US
Telephone Number	:	315-668-0422
Fax Number	:

Provider Business Practice Location Address
First Line	:	3018 EAST AVE
Second Line	:
City	:	CENTRAL SQUARE
State	:	NY
Zip	:	13036-2713
Country	:	US
Telephone Number	:	315-668-0422
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2024
Last Update Date	:	09/19/2024

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Directions to “ NICOLE M BROADWELL ” Practice Location

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