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General NPI Number Information
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NPI Number | 1285383737
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Entity Type | Organization
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Legal Business Name | CRYSTALEYES, LLC
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Dates
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Enumeration Date | 03/22/2022
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Last Update Date | 11/07/2022
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Provider Practice Location Address
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Address Line | 1220 TAMARACK AVENUE INDEPENDENT OPTOMETRISTS INSIDE OF COSTCO
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-5572
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Country | US
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Telephone | 860-474-4046
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Fax | 860-474-4045
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Provider Business Mailing Address
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Address Line | 1220 TAMARACK AVE
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074-5572
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Country | US
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Telephone | 860-474-4046
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Fax | 860-474-4045
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Authorized Official
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Title or Position | OWNER, MANAGING MEMBER
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Name | DR. DEVINA PATEL
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Credential | O.D., FAAO
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Telephone | 860-474-4046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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