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General NPI Number Information
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NPI Number | 1962657205
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Entity Type | Organization
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Legal Business Name | 20-20 CRYSTAL CLEAR VISION PA
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Dates
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Enumeration Date | 12/01/2008
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Last Update Date | 04/29/2010
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Provider Practice Location Address
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Address Line | 10004 WURZBACH RD
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City | SAN ANTONIO
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State | TX
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Zip | 78230-2214
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Country | US
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Telephone | 210-563-9694
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 781603
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City | SAN ANTONIO
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State | TX
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Zip | 78278-1603
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Country | US
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Telephone | 210-563-9694
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EDWARD BUSTAMANTE
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Credential | O.D.,M.B.A
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Telephone | 210-563-9694
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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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