Provider Demographics
NPI:1962657205
Name:20-20 CRYSTAL CLEAR VISION PA
Entity Type:Organization
Organization Name:20-20 CRYSTAL CLEAR VISION PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BUSTAMANTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD,MBA
Authorized Official - Phone:210-563-9694
Mailing Address - Street 1:PO BOX 781603
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78278-1603
Mailing Address - Country:US
Mailing Address - Phone:210-563-9694
Mailing Address - Fax:
Practice Address - Street 1:10004 WURZBACH RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2214
Practice Address - Country:US
Practice Address - Phone:210-563-9694
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-01
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty