1689891368 NPI number — CRYSTAL CLEAR EYECARE INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689891368 NPI number — CRYSTAL CLEAR EYECARE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CLEAR EYECARE INC.
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:
Provider Other Organization Name Type Code:
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:
1689891368
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 599
Provider Second Line Business Mailing Address:
2979 LINCOLN HWY
Provider Business Mailing Address City Name:
SADSBURYVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19369-0599
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-857-2291
Provider Business Mailing Address Fax Number:
610-857-2297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2979 LINCOLN HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SADSBURYVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-857-2291
Provider Business Practice Location Address Fax Number:
610-857-2297
Provider Enumeration Date:
04/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SULAK
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
215-872-0827

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OEG001443 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0018808050004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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