MEDICARE: CRYSTAL CLEAR IMAGING INC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	2471V0105X	Vascular Sonography Radiologic Technologist
2	2471S1302X	Sonography Radiologic Technologist
3	246XS1301X	Sonography Specialist/Technologist Cardiovascular

General Provider Information

NPI Number	:	1750642229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL CLEAR IMAGING INC

Provider Business Mailing Address
First Line	:	PO BOX 21644
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33742-1644
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4051 FARGO ST N
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33714-4550
Country	:	US
Telephone Number	:	941-228-8660
Fax Number	:

Authorized Official
Title or Position	:	SECRETARY
Name	:	MRS. CRYSTAL MERCADO
Credential	:
Telephone Number	:	941-228-8660

Provider Enumeration Date	:	05/31/2012
Last Update Date	:	06/13/2012

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