Healthcare Provider Details

I. General information

NPI: 1962662379
Provider Name (Legal Business Name): BROADLAWNS MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

IV. Provider business mailing address

1801 HICKMAN RD
DES MOINES IA
50314-1505
US

V. Phone/Fax

Practice location:
  • Phone: 515-282-2200
  • Fax:
Mailing address:
  • Phone: 515-282-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number4703006
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. VINCENT J MANDRACCHIA
Title or Position: CHIEF MEDICAL OFFICER
Credential: DPM
Phone: 515-282-2562