Provider Demographics
NPI:1265101158
Name:BROADWAY FAMILY OPTOMETRY
Entity type:Organization
Organization Name:BROADWAY FAMILY OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MARDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:818-241-7719
Mailing Address - Street 1:113 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1006
Mailing Address - Country:US
Mailing Address - Phone:818-241-7719
Mailing Address - Fax:
Practice Address - Street 1:113 E BROADWAY
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1006
Practice Address - Country:US
Practice Address - Phone:818-241-7719
Practice Address - Fax:818-241-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty