Provider Demographics
NPI:1205012416
Name:KRYSTAL CLEAR OPTICAL INC.
Entity Type:Organization
Organization Name:KRYSTAL CLEAR OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CADDELL
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:575-887-2919
Mailing Address - Street 1:203 W FOX ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5736
Mailing Address - Country:US
Mailing Address - Phone:575-887-2919
Mailing Address - Fax:575-885-2713
Practice Address - Street 1:203 W FOX ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-5736
Practice Address - Country:US
Practice Address - Phone:575-887-2919
Practice Address - Fax:575-885-2713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02-477397-00-2332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier