MEDICARE: CRYSTAL VISION OPTOMETRY GROUP

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	OPT11575TPL	CA

General Provider Information

NPI Number	:	1932536869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL VISION OPTOMETRY GROUP

Provider Business Mailing Address
First Line	:	11940 EAST FOOTHILL BLVD
Second Line	:	SUITE 103
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-2892
Country	:	US
Telephone Number	:	909-234-4222
Fax Number	:	909-568-2413

Provider Business Practice Location Address
First Line	:	11940 EAST FOOTHILL BLVD
Second Line	:	SUITE 103
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-9173
Country	:	US
Telephone Number	:	909-234-4222
Fax Number	:	909-568-2413

Authorized Official
Title or Position	:	OWNER
Name	:	LEENA GAYAKWAD ADHIKARI
Credential	:	OD
Telephone Number	:	909-980-5552

Provider Enumeration Date	:	10/10/2013
Last Update Date	:	04/20/2023

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