Healthcare Provider Details

I. General information

NPI: 1750642229
Provider Name (Legal Business Name): CRYSTAL CLEAR IMAGING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4051 FARGO ST N
SAINT PETERSBURG FL
33714-4550
US

IV. Provider business mailing address

PO BOX 21644
ST PETERSBURG FL
33742-1644
US

V. Phone/Fax

Practice location:
  • Phone: 941-228-8660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name: MRS. CRYSTAL MERCADO
Title or Position: SECRETARY
Credential:
Phone: 941-228-8660