Provider Demographics
NPI:1295877645
Name:BROAD EXPRESS, INCORPORATED
Entity type:Organization
Organization Name:BROAD EXPRESS, INCORPORATED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BABATUNDE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:ADEBIYI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-264-4448
Mailing Address - Street 1:2604 W MARSHALL DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3555
Mailing Address - Country:US
Mailing Address - Phone:972-264-4448
Mailing Address - Fax:972-642-7886
Practice Address - Street 1:2604 W MARSHALL DR
Practice Address - Street 2:SUITE 104
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3555
Practice Address - Country:US
Practice Address - Phone:972-264-4448
Practice Address - Fax:972-642-7886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0092486332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184098501Medicaid
TX184098502Medicaid
TX0000532440OtherBLUECROSS BLUESHIELD
TX184098501Medicaid