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General NPI Number Information
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NPI Number | 1700290160
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Entity Type | Organization
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Legal Business Name | BROADWAY OPTICAL CORP
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Dates
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Enumeration Date | 06/13/2014
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Last Update Date | 06/13/2014
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Provider Practice Location Address
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Address Line | 333 BROADWAY STREET SUITE 1
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City | REVERE
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State | MA
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Zip | 02151
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Country | US
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Telephone | 781-289-0489
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Fax |
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Provider Business Mailing Address
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Address Line | 333 BROADWAY SUITE 1
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City | REVERE
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State | MA
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Zip | 02151-5017
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Country | US
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Telephone | 781-289-0489
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MR. WILLIAM MASIELLO
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Credential | OPTICAN
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Telephone | 781-289-0489
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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