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NPI Code Detail

MEDICARE: BROADSCOPE LLC

MEDICARE: BROADSCOPE 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
1251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1922251404
Entity Type Code : Organization
Provider Name (Legal Business Name) : BROADSCOPE LLC
Provider Business Mailing Address
First Line : 12139 MOUNT VERNON AVE STE 101
Second Line :
City : GRAND TERRACE
State : CA
Zip : 92313-5519
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 12139 MOUNT VERNON AVE STE 101
Second Line :
City : GRAND TERRACE
State : CA
Zip : 92313-5519
Country : US
Telephone Number : 951-440-2730
Fax Number :
Authorized Official
Title or Position : COO
Name : MEELYNDA RAYFORD
Credential :
Telephone Number : 951-440-2730
Provider Enumeration Date : 10/29/2008
Last Update Date : 10/30/2008

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Directions to “BROADSCOPE LLC ” Practice Location

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