Provider Demographics
NPI:1174926653
Name:CRYSTAL VISION WEST HARTFORD LLC.
Entity type:Organization
Organization Name:CRYSTAL VISION WEST HARTFORD LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:860-442-0380
Mailing Address - Street 1:909 HARTFORD TPKE
Mailing Address - Street 2:UNIT D2
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-4267
Mailing Address - Country:US
Mailing Address - Phone:860-442-0380
Mailing Address - Fax:860-437-1717
Practice Address - Street 1:64 RAYMOND RD
Practice Address - Street 2:SUITE170
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2213
Practice Address - Country:US
Practice Address - Phone:860-442-0380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002229152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty