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General NPI Number Information
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NPI Number | 1962807586
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Entity Type | Organization
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Legal Business Name | CRYSTAL FALLS VISION CENTER, PLLC
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Dates
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Enumeration Date | 10/24/2014
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Last Update Date | 10/24/2014
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Provider Practice Location Address
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Address Line | 3550 LAKELINE BLVD STE 180
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City | LEANDER
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State | TX
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Zip | 78641
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Country | US
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Telephone | 281-235-3589
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Fax |
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Provider Business Mailing Address
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Address Line | 3807 SEBASTIAN CV
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City | ROUND ROCK
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State | TX
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Zip | 78681-2332
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST/OWNER
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Name | DR. BRADLY MATHEW
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Credential | O.D.
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Telephone | 281-235-3589
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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 | 6940TG
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License Number State | TX
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