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General NPI Number Information
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NPI Number | 1780719807
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Entity Type | Organization
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Legal Business Name | BROADWAY VISION SOURCE
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | BROADWAY VISION SOURCE 301 A EAST PIKE ST.
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City | SEATTLE
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State | WA
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Zip | 98122-3609
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Country | US
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Telephone | 206-464-0472
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Fax | 206-464-0572
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Provider Business Mailing Address
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Address Line | BROADWAY VISION SOURCE 301 A EAST PIKE ST.
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City | SEATTLE
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State | WA
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Zip | 98122
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Country | US
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Telephone | 206-464-0472
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Fax | 206-464-0572
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Authorized Official
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Title or Position | DOCTER
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Name | DR. MICHAEL MATSUNAMI
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Credential | O.D
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Telephone | 206-464-0742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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