Provider Demographics
NPI:1629484670
Name:CRYSTAL CLEAR VISION, LLC
Entity Type:Organization
Organization Name:CRYSTAL CLEAR VISION, LLC
Other - Org Name:PURE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANEHOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-874-3661
Mailing Address - Street 1:1021 SANDUSKY ST STE E
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3201
Mailing Address - Country:US
Mailing Address - Phone:419-874-3661
Mailing Address - Fax:419-872-5195
Practice Address - Street 1:1021 SANDUSKY ST STE E
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3201
Practice Address - Country:US
Practice Address - Phone:419-874-3661
Practice Address - Fax:419-872-5195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5820/T2734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3126254Medicaid