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General NPI Number Information
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NPI Number | 1255927240
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Entity Type | Organization
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Legal Business Name | CRYSTAL CLEAR OPTIQUE
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Dates
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Enumeration Date | 12/14/2020
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Last Update Date | 12/14/2020
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Provider Practice Location Address
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Address Line | 840 GLYNN ST S STE 344
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City | FAYETTEVILLE
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State | GA
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Zip | 30214-2004
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Country | US
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Telephone | 770-716-7414
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Fax | 770-716-7498
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Provider Business Mailing Address
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Address Line | 7492 PARKLAND BND
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City | FAIRBURN
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State | GA
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Zip | 30213-5422
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Country | US
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Telephone | 678-800-2030
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Fax | 770-716-7498
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Authorized Official
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Title or Position | CEO
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Name | DR. CRYSTAL WADE
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Credential |
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Telephone | 770-716-7414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WV0400X
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Taxonomy Name | Vision Therapy Optometrist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FC0800X
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Taxonomy Name | Contact Lens Technician/Technologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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