Organization
BROADWAY VISION SOURCE, INCORPORATED
Active
Parent organization
BROADWAY VISION SOURCE, INCORPORATED
Organization subpart
Yes
Provider details
NPI number
Legal business name
BROADWAY VISION SOURCE, INCORPORATED
Authorized official
BRANDON S HAUCK O.D (OWNER)
(515) 448-3813
Entity
Organization
Contact information
Practice address
300 W BROADWAY ST, EAGLE GROVE, IA 50533-1712
(515) 448-3813
(515) 448-3885
Mailing address
300 W BROADWAY ST, P.O BOX 459, EAGLE GROVE, IA 50533-1712
(515) 448-3813
(515) 448-3885
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1346620432
INDIVIDUAL NPI
IA
05
—
1346620432
—
IA
Enumeration date
11/14/2018
Last updated
11/14/2018
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