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General NPI Number Information
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NPI Number | 1609848878
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Entity Type | Organization
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Legal Business Name | BROADLAWNS MEDICAL CENTER
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Dates
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Enumeration Date | 02/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1801 HICKMAN RD
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City | DES MOINES
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State | IA
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Zip | 50314-1505
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Country | US
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Telephone | 515-282-2421
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Fax |
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Provider Business Mailing Address
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Address Line | 1801 HICKMAN ROAD
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City | DES MOINES
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State | IA
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Zip | 50314-1505
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Country | US
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Telephone | 515-282-2421
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Fax |
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Authorized Official
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Title or Position | CHIEF MEDICAL OFFICER
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Name | DR. VINCENT J MANDRACCHIA
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Credential | DPM
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Telephone | 515-282-2562
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 07724
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License Number State | IA
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