MEDICARE: BROOME VISION INC

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	OPC3301	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689838393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOME VISION INC

Provider Business Mailing Address
First Line	:	1474 W GRANADA BLVD
Second Line	:	STE 470
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-9187
Country	:	US
Telephone Number	:	386-673-3011
Fax Number	:

Provider Business Practice Location Address
First Line	:	1474 W GRANADA BLVD
Second Line	:	SUITE 470
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-9187
Country	:	US
Telephone Number	:	386-673-3011
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/OWNER
Name	:	KEVIN ANDREW BROOME
Credential	:	O.D.
Telephone Number	:	386-253-5999

Provider Enumeration Date	:	07/11/2008
Last Update Date	:	06/02/2011

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Directions to “BROOME VISION INC ” Practice Location

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