MEDICARE: BROADWAY VISION SOURCE

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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1780719807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY VISION SOURCE

Provider Business Mailing Address
First Line	:	BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122
Country	:	US
Telephone Number	:	206-464-0472
Fax Number	:	206-464-0572

Provider Business Practice Location Address
First Line	:	BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-3609
Country	:	US
Telephone Number	:	206-464-0472
Fax Number	:	206-464-0572

Authorized Official
Title or Position	:	DOCTER
Name	:	DR. MICHAEL MATSUNAMI
Credential	:	O.D
Telephone Number	:	206-464-0742

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	08/22/2020

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