Basic Information
| Provider Information | |||||||||
| NPI: | 1073137568 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUMBACK | ||||||||
| FirstName: | TORIA | ||||||||
| MiddleName: | RAE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442441818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5821 W MAPLE RD STE 195 | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483222275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488310293 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2020 | ||||||||
| LastUpdateDate: | 03/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | N | Eye and Vision Services Providers | Technician/Technologist | 106S00000X | Y |
No ID Information.