Healthcare Provider Details

I. General information

NPI: 1053095968
Provider Name (Legal Business Name): BROADWAY HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1622 E BROADWAY ST
MUSKOGEE OK
74403-4601
US

IV. Provider business mailing address

477 N LINDBERGH BLVD STE 310
SAINT LOUIS MO
63141-7856
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-2851
  • Fax:
Mailing address:
  • Phone: 314-631-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: NAFTALI FRIEDMAN
Title or Position: MANAGER
Credential:
Phone: 314-631-3000