Healthcare Provider Details

I. General information

NPI: 1215721824
Provider Name (Legal Business Name): BROADWAY OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 BROAD AVE
PALISADES PARK NJ
07650-1509
US

IV. Provider business mailing address

204 BROAD AVE
PALISADES PARK NJ
07650-1509
US

V. Phone/Fax

Practice location:
  • Phone: 201-585-7111
  • Fax:
Mailing address:
  • Phone: 201-585-7111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEANINE ELIZABETH GRAVES
Title or Position: OPTOMETRIST
Credential: OD
Phone: 201-310-6947