Provider Demographics
NPI:1700290160
Name:BROADWAY OPTICAL CORP
Entity Type:Organization
Organization Name:BROADWAY OPTICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MASIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICAN
Authorized Official - Phone:781-289-0489
Mailing Address - Street 1:333 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-5017
Mailing Address - Country:US
Mailing Address - Phone:781-289-0489
Mailing Address - Fax:
Practice Address - Street 1:333 BROADWAY STREET
Practice Address - Street 2:SUITE 1
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151
Practice Address - Country:US
Practice Address - Phone:781-289-0489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty