Provider Demographics
NPI:1932273026
Name:CRYSTAL CLEAR VISION CORP.
Entity Type:Organization
Organization Name:CRYSTAL CLEAR VISION CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ERICKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-692-5800
Mailing Address - Street 1:1 N GALLERIA DR STE 126N
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3028
Mailing Address - Country:US
Mailing Address - Phone:845-692-5800
Mailing Address - Fax:845-692-5880
Practice Address - Street 1:1 N GALLERIA DR STE 126N
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3028
Practice Address - Country:US
Practice Address - Phone:845-692-5800
Practice Address - Fax:845-692-5880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002805152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02706105Medicaid
NYA100085711Medicare PIN