1285383737 NPI number — CRYSTALEYES, LLC

Table of content: (NPI 1285383737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285383737 NPI number — CRYSTALEYES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTALEYES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEVINA PATEL, O.D., LLC
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285383737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1220 TAMARACK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH WINDSOR
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06074-5572
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-474-4046
Provider Business Mailing Address Fax Number:
860-474-4045

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1220 TAMARACK AVENUE
Provider Second Line Business Practice Location Address:
INDEPENDENT OPTOMETRISTS INSIDE OF COSTCO
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074-5572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-474-4046
Provider Business Practice Location Address Fax Number:
860-474-4045
Provider Enumeration Date:
03/22/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PATEL
Authorized Official First Name:
DEVINA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, MANAGING MEMBER
Authorized Official Telephone Number:
860-474-4046

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1588895700 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1538475132 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1831219278 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".