Provider Demographics
NPI:1922193903
Name:CRYSTAL CLEAR OPTICS
Entity Type:Organization
Organization Name:CRYSTAL CLEAR OPTICS
Other - Org Name:OPTIQUE LTD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/ OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:CORRIEA
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:508-947-6300
Mailing Address - Street 1:10 MERCHANTS WAY
Mailing Address - Street 2:SUITE H
Mailing Address - City:MIDDLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02346
Mailing Address - Country:US
Mailing Address - Phone:508-947-6300
Mailing Address - Fax:508-946-0900
Practice Address - Street 1:10 MERCHANTS WAY
Practice Address - Street 2:SUITE H
Practice Address - City:MIDDLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02346
Practice Address - Country:US
Practice Address - Phone:508-947-6300
Practice Address - Fax:508-946-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA4970332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1537024Medicaid
MAQ00345OtherBLUE CROSS BL;UE SHEILD
MA1106670001Medicare NSC