Provider Demographics
NPI:1922294966
Name:CRYSTAL EYES OPTICAL, LLC
Entity Type:Organization
Organization Name:CRYSTAL EYES OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLESS
Authorized Official - Middle Name:
Authorized Official - Last Name:SESSIONS
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:772-978-1172
Mailing Address - Street 1:4165 9TH ST SW
Mailing Address - Street 2:SUITE 106
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32968-4878
Mailing Address - Country:US
Mailing Address - Phone:772-978-1172
Mailing Address - Fax:772-978-1173
Practice Address - Street 1:4165 9TH ST SW
Practice Address - Street 2:SUITE 106
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32968-4878
Practice Address - Country:US
Practice Address - Phone:772-978-1172
Practice Address - Fax:772-978-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO5603261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service