MEDICARE: CHASSIE A BROADUS O.D.

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	18003924A	IN

General Provider Information

NPI Number	:	1265817274
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHASSIE A BROADUS O.D.

Provider Business Mailing Address
First Line	:	401 HENRY ST
Second Line	:
City	:	NORTH VERNON
State	:	IN
Zip	:	47265-1003
Country	:	US
Telephone Number	:	812-346-2020
Fax Number	:	812-346-4636

Provider Business Practice Location Address
First Line	:	401 HENRY ST
Second Line	:
City	:	NORTH VERNON
State	:	IN
Zip	:	47265-1003
Country	:	US
Telephone Number	:	812-346-2020
Fax Number	:	812-346-4636

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2015
Last Update Date	:	07/21/2015

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