1629484670 NPI number — CRYSTAL CLEAR VISION, LLC

Table of content: (NPI 1629484670)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629484670 NPI number — CRYSTAL CLEAR VISION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRYSTAL CLEAR VISION, 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:
Provider Other Organization Name Type Code:
6
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:
1629484670
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1021 SANDUSKY ST STE E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRYSBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43551-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-874-3661
Provider Business Mailing Address Fax Number:
419-872-5195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1021 SANDUSKY ST STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-874-3661
Provider Business Practice Location Address Fax Number:
419-872-5195
Provider Enumeration Date:
07/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SANEHOLTZ
Authorized Official First Name:
AUSTIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
419-874-3661

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  5820/T2734 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3126254 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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