Provider Demographics
NPI:1992167407
Name:BROOME EYE CARE AND OPTICAL PA
Entity type:Organization
Organization Name:BROOME EYE CARE AND OPTICAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BROOME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-466-1062
Mailing Address - Street 1:125 SW MIDTOWN PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0766
Mailing Address - Country:US
Mailing Address - Phone:386-466-1062
Mailing Address - Fax:386-466-1061
Practice Address - Street 1:125 SW MIDTOWN PL
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0766
Practice Address - Country:US
Practice Address - Phone:386-466-1062
Practice Address - Fax:386-466-1061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1679554760152W00000X
FL1992167407305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIQ475AMedicare PIN
FL078744200Medicare PIN