MEDICARE: CRYSTAL VISION, ODPA

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	NC1811	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548446701
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL VISION, ODPA

Provider Business Mailing Address
First Line	:	710 MILITARY CUTOFF RD STE 130
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-2382
Country	:	US
Telephone Number	:	910-447-2020
Fax Number	:	866-984-3914

Provider Business Practice Location Address
First Line	:	710 MILITARY CUTOFF RD STE 130
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28405-2382
Country	:	US
Telephone Number	:	910-447-2020
Fax Number	:	866-984-3914

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CRYSTAL M. BRIMER
Credential	:	OD
Telephone Number	:	910-447-2020

Provider Enumeration Date	:	01/17/2008
Last Update Date	:	04/03/2024

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