MEDICARE: CRYSTAL CLEAR EYECARE, 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	1666-700AT	LA

General Provider Information

NPI Number	:	1790150225
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL CLEAR EYECARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 2128
Second Line	:
City	:	PONCHATOULA
State	:	LA
Zip	:	70454-2128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	139 W OAK ST
Second Line	:
City	:	PONCHATOULA
State	:	LA
Zip	:	70454-3328
Country	:	US
Telephone Number	:	985-467-1223
Fax Number	:	985-467-0979

Authorized Official
Title or Position	:	OWNER/OPTOMETRIST
Name	:	CRYSTAL GUELDNER
Credential	:	O.D
Telephone Number	:	985-467-1223

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	02/12/2020

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