Provider Demographics
NPI:1174573380
Name:CRYSTAL VISION OPTOMETRY, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:CRYSTAL VISION OPTOMETRY, A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANH-LINH
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:714-531-9900
Mailing Address - Street 1:3801 S HARBOR BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7901
Mailing Address - Country:US
Mailing Address - Phone:714-531-9900
Mailing Address - Fax:714-531-0236
Practice Address - Street 1:16125 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1305
Practice Address - Country:US
Practice Address - Phone:714-531-9900
Practice Address - Fax:714-531-0236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10146T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101460Medicaid
CAU53409Medicare UPIN
CASD0101460Medicaid