MEDICARE: BROECKER EYE & OPTICAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2108	MN

General Provider Information

NPI Number	:	1114962529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROECKER EYE & OPTICAL

Provider Business Mailing Address
First Line	:	2356 UNIVERSITY AVE W
Second Line	:	SUITE 260
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1853
Country	:	US
Telephone Number	:	651-645-8124
Fax Number	:	651-645-8125

Provider Business Practice Location Address
First Line	:	2356 UNIVERSITY AVE W
Second Line	:	SUITE 260
City	:	SAINT PAUL
State	:	MN
Zip	:	55114-1853
Country	:	US
Telephone Number	:	651-645-8124
Fax Number	:	651-645-8125

Authorized Official
Title or Position	:	OPTOMETRIST
Name	:	STACEY T. BROECKER
Credential	:	O.D.
Telephone Number	:	651-645-8124

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	08/22/2020

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