Basic Information
| Provider Information | |||||||||
| NPI: | 1548446701 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL VISION, ODPA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1319 MILITARY CUTOFF RD STE II | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104472020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1319 MILITARY CUTOFF RD STE II | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104472020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2008 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | BRIMER | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9107900212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | NC1811 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 89014TC | 05 | NC | MEDICAID |