Provider Demographics
NPI:1811136872
Name:CRYSTAL COVE EYE CONSULTANTS, LLC
Entity type:Organization
Organization Name:CRYSTAL COVE EYE CONSULTANTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:GIESE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:480-290-1470
Mailing Address - Street 1:PO BOX 6292
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85261-6292
Mailing Address - Country:US
Mailing Address - Phone:480-290-1470
Mailing Address - Fax:
Practice Address - Street 1:700 N 54TH ST
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-1502
Practice Address - Country:US
Practice Address - Phone:480-893-2333
Practice Address - Fax:480-893-8895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty