MEDICARE: BROADWAY MEDICAL INNOVATION, LLC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1467108514
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY MEDICAL INNOVATION, LLC

Provider Business Mailing Address
First Line	:	4016 RIVER OAKS DR STE 6 PMB 178
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-6674
Country	:	US
Telephone Number	:	843-655-0004
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WATER GRANDE BLVD
Second Line	:
City	:	LITTLE RIVER
State	:	SC
Zip	:	29566
Country	:	US
Telephone Number	:	843-655-0004
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VICTOR AGUIN MELENDEZ
Credential	:	MD
Telephone Number	:	843-655-0004

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	04/22/2026

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