MEDICARE: KRYSTAL VISION CENTER INC

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	OEG000225	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HIGHMARK	OTHER	PA	1626663
2	AETNA	OTHER	PA	3548372
3	IBC	OTHER	PA	2308658000

General Provider Information

NPI Number	:	1609806777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KRYSTAL VISION CENTER INC

Provider Business Mailing Address
First Line	:	6533 ROOSEVELT BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2918
Country	:	US
Telephone Number	:	215-744-6727
Fax Number	:	215-744-1622

Provider Business Practice Location Address
First Line	:	6533 ROOSEVELT BLVD
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2918
Country	:	US
Telephone Number	:	215-744-6727
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KRYSTAL T NGUYEN
Credential	:	O.D.
Telephone Number	:	215-744-6727

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	03/03/2011

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Directions to “KRYSTAL VISION CENTER INC ” Practice Location

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