Provider Demographics
NPI:1568422335
Name:DESERT MEDICAL EYE CENTER OPTICAL SHOP
Entity Type:Organization
Organization Name:DESERT MEDICAL EYE CENTER OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRAYTHORN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-734-9585
Mailing Address - Street 1:4324 S EASTERN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6016
Mailing Address - Country:US
Mailing Address - Phone:702-734-9585
Mailing Address - Fax:702-734-9518
Practice Address - Street 1:4324 S EASTERN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6016
Practice Address - Country:US
Practice Address - Phone:702-734-9585
Practice Address - Fax:702-734-9518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5468332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
18005746Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
060332001Medicare ID - Type Unspecified