1780719807 NPI number — BROADWAY VISION SOURCE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780719807 NPI number — BROADWAY VISION SOURCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY VISION SOURCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780719807
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-464-0472
Provider Business Mailing Address Fax Number:
206-464-0572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BROADWAY VISION SOURCE 301 A EAST PIKE ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEATTLE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98122-3609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
206-464-0472
Provider Business Practice Location Address Fax Number:
206-464-0572
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MATSUNAMI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTER
Authorized Official Telephone Number:
206-464-0742

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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