Provider Demographics
NPI:1689891368
Name:CRYSTAL CLEAR EYECARE INC.
Entity Type:Organization
Organization Name:CRYSTAL CLEAR EYECARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SULAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-872-0827
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:2979 LINCOLN HWY
Mailing Address - City:SADSBURYVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19369-0599
Mailing Address - Country:US
Mailing Address - Phone:610-857-2291
Mailing Address - Fax:610-857-2297
Practice Address - Street 1:2979 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:SADSBURYVILLE
Practice Address - State:PA
Practice Address - Zip Code:19369
Practice Address - Country:US
Practice Address - Phone:610-857-2291
Practice Address - Fax:610-857-2297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001443152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018808050004Medicaid
PA0018808050004Medicaid