Healthcare Provider Details

I. General information

NPI: 1215148564
Provider Name (Legal Business Name): CRYSTAL CLEAR EYEGLASS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4946 N 5TH ST 1ST FL
PHILADELPHIA PA
19120
US

IV. Provider business mailing address

4946 N 5TH ST 1ST FL
PHILADELPHIA PA
19120
US

V. Phone/Fax

Practice location:
  • Phone: 215-924-4142
  • Fax: 215-924-4143
Mailing address:
  • Phone: 215-924-4142
  • Fax: 215-924-4143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: TOMAS L CASTILLO
Title or Position: OWNER OPTICIAN
Credential:
Phone: 215-924-4142