Provider Demographics
NPI:1568909166
Name:CRYSTAL VIEW OPTOMETRY, INC.
Entity Type:Organization
Organization Name:CRYSTAL VIEW OPTOMETRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:916-681-1101
Mailing Address - Street 1:8419 ELK GROVE FLORIN RD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9518
Mailing Address - Country:US
Mailing Address - Phone:916-681-1101
Mailing Address - Fax:916-682-8891
Practice Address - Street 1:8419 ELK GROVE FLORIN RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624-9518
Practice Address - Country:US
Practice Address - Phone:916-681-1101
Practice Address - Fax:916-682-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11307TPG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU79323Medicare UPIN