Provider Demographics
NPI:1407976780
Name:CRYSTAL VISION CENTER PC
Entity Type:Organization
Organization Name:CRYSTAL VISION CENTER PC
Other - Org Name:CRYSTAL VISION CENTER, P.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:YORKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:979-764-0669
Mailing Address - Street 1:2551B TEXAS AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-4629
Mailing Address - Country:US
Mailing Address - Phone:979-764-0669
Mailing Address - Fax:979-694-1940
Practice Address - Street 1:2551B TEXAS AVE SOUTH
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-4629
Practice Address - Country:US
Practice Address - Phone:979-764-0669
Practice Address - Fax:979-694-1940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2905T152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82FBOtherBLUE CROSS BLUE SHIELD
TX093395402Medicaid
TX82FBOtherBLUE CROSS BLUE SHIELD