Provider Demographics
NPI:1497935829
Name:CRATER VISION INC
Entity Type:Organization
Organization Name:CRATER VISION INC
Other - Org Name:CRATER VISION CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-732-3937
Mailing Address - Street 1:3333 S CRATER RD STE 2D
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9276
Mailing Address - Country:US
Mailing Address - Phone:804-732-3937
Mailing Address - Fax:807-733-6005
Practice Address - Street 1:3333 S CRATER RD STE 2D
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9276
Practice Address - Country:US
Practice Address - Phone:804-732-3937
Practice Address - Fax:807-733-6005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009235221Medicaid
VA080634OtherBLUE CROSS
VA009235221Medicaid
VAC03755Medicare PIN