Basic Information
| Provider Information | |||||||||
| NPI: | 1336454800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EMBASSY BROADWAY MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROADWAY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16231 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441372526 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 16231 BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441372526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166620551 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 08/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | HANDLER | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2166620551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EMBASSY BROADWAY MANAGEMENT, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.