Healthcare Provider Details

I. General information

NPI: 1114612314
Provider Name (Legal Business Name): KRYSTAL CLEAR IMAGING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 03/14/2025
Certification Date: 03/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 JEFFERSON ST NE
ALBUQUERQUE NM
87109-4450
US

IV. Provider business mailing address

1529 PEPPOLI LOOP SE
RIO RANCHO NM
87124-8775
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-0372
  • Fax:
Mailing address:
  • Phone: 505-303-0372
  • 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 TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL GRIEGO
Title or Position: OWNER
Credential:
Phone: 505-977-4788