Provider Demographics
NPI:1396527222
Name:EYES ON BROADWAY SA INC
Entity type:Organization
Organization Name:EYES ON BROADWAY SA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FUZAYLOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-412-3750
Mailing Address - Street 1:825 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-4702
Mailing Address - Country:US
Mailing Address - Phone:212-475-0999
Mailing Address - Fax:
Practice Address - Street 1:825 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-475-0999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty