Basic Information
| Provider Information | |||||||||
| NPI: | 1003921180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERTHELETTE | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOYNER | ||||||||
| OtherFirstName: | KRYSTAL | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 119 LATONEA DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292107572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037988642 | ||||||||
| FaxNumber: | 8037988642 | ||||||||
| Practice Location | |||||||||
| Address1: | 5420 FOREST DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292065401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037904600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 1415 | SC | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.