Provider Demographics
NPI:1831378843
Name:CRUM OPTOMETRIC GROUP, INC
Entity type:Organization
Organization Name:CRUM OPTOMETRIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:CRUM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:909-393-8378
Mailing Address - Street 1:2581 CHINO HILLS PKWY
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5117
Mailing Address - Country:US
Mailing Address - Phone:909-393-8378
Mailing Address - Fax:909-393-0228
Practice Address - Street 1:2581 CHINO HILLS PKWY
Practice Address - Street 2:SUITE C
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5117
Practice Address - Country:US
Practice Address - Phone:909-393-8378
Practice Address - Fax:909-393-0228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9524T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095240Medicaid
CASD0095240Medicaid
CASD0095240OtherMEDICARE
CAU50049Medicare UPIN