Provider Demographics
NPI:1326483405
Name:WADE, CRYSTAL (LDO)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7492 PARKLAND BND
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-5422
Mailing Address - Country:US
Mailing Address - Phone:678-777-1824
Mailing Address - Fax:
Practice Address - Street 1:1240 HIGHWAY 54 W
Practice Address - Street 2:306
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4557
Practice Address - Country:US
Practice Address - Phone:678-304-7129
Practice Address - Fax:877-543-7919
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002220156FC0801X, 156FC0800X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No156FC0800XEye and Vision Services ProvidersTechnician/TechnologistContact Lens