MEDICARE: CRYSTAL VISION, 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	156FX1800X	Optician	L980322	AR

General Provider Information

NPI Number	:	1922355585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL VISION, INC

Provider Business Mailing Address
First Line	:	2935 LAKEWOOD VILLAGE DR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-8033
Country	:	US
Telephone Number	:	501-516-1227
Fax Number	:

Provider Business Practice Location Address
First Line	:	2935 LAKEWOOD VILLAGE DR
Second Line	:
City	:	NORTH LITTLE ROCK
State	:	AR
Zip	:	72116-8033
Country	:	US
Telephone Number	:	501-516-1227
Fax Number	:

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	LISA VEREE JACOBS
Credential	:	LICENSED OPTICIAN
Telephone Number	:	501-516-1227

Provider Enumeration Date	:	08/13/2012
Last Update Date	:	08/13/2012

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