MEDICARE: CRYSTAL VISION CONSULTANTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4901004359	MI

General Provider Information

NPI Number	:	1184133498
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL VISION CONSULTANTS, LLC

Provider Business Mailing Address
First Line	:	2211 S TELEGRAPH RD UNIT 7061
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48302-4802
Country	:	US
Telephone Number	:	586-745-0863
Fax Number	:

Provider Business Practice Location Address
First Line	:	29273 DEQUINDRE RD
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-4804
Country	:	US
Telephone Number	:	586-745-0863
Fax Number	:	586-232-5502

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KENNETH WONG
Credential	:	OD
Telephone Number	:	586-381-2789

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	07/29/2024

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