Provider Demographics
NPI:1215721824
Name:BROADWAY OPTICAL LLC
Entity type:Organization
Organization Name:BROADWAY OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:201-310-6947
Mailing Address - Street 1:204 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1509
Mailing Address - Country:US
Mailing Address - Phone:201-585-7111
Mailing Address - Fax:
Practice Address - Street 1:204 BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1509
Practice Address - Country:US
Practice Address - Phone:201-585-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty