Healthcare Provider Details

I. General information

NPI: 1891958963
Provider Name (Legal Business Name): BROOME VISION INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3781O S NOVA RD STE O
PORT ORANGE FL
32129-4233
US

IV. Provider business mailing address

3781 S NOVA RD STE O
PORT ORANGE FL
32129-4285
US

V. Phone/Fax

Practice location:
  • Phone: 386-760-8626
  • Fax: 386-760-2676
Mailing address:
  • Phone: 386-760-8626
  • Fax: 386-760-2676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3301
License Number StateFL

VIII. Authorized Official

Name: KEVIN ANDREW BROOME
Title or Position: PRESIDENT/OWNER
Credential: O.D.
Phone: 386-253-5999