Healthcare Provider Details

I. General information

NPI: 1255927240
Provider Name (Legal Business Name): CRYSTAL CLEAR OPTIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 GLYNN ST S STE 344
FAYETTEVILLE GA
30214-2004
US

IV. Provider business mailing address

7492 PARKLAND BND
FAIRBURN GA
30213-5422
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-7414
  • Fax: 770-716-7498
Mailing address:
  • Phone: 678-800-2030
  • Fax: 770-716-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: DR. CRYSTAL WADE
Title or Position: CEO
Credential:
Phone: 770-716-7414