MEDICARE: JOHN H BROADDUS

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	152W00000X	Optometrist	OEG001548	PA

General Provider Information

NPI Number	:	1265538045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN H BROADDUS

Provider Business Mailing Address
First Line	:	1158 PARK CITY CTR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17601-2726
Country	:	US
Telephone Number	:	717-393-4042
Fax Number	:

Provider Business Practice Location Address
First Line	:	1158 PARK CITY CTR
Second Line	:
City	:	LANCASTER
State	:	PA
Zip	:	17601-2726
Country	:	US
Telephone Number	:	717-393-4042
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN HALE BROADDUS
Credential	:	OD
Telephone Number	:	717-393-4042

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	10/30/2007

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