MEDICARE: KATHIE JOY CRISP LDO

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	DO5913	FL

General Provider Information

NPI Number	:	1992496913
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHIE JOY CRISP LDO

Provider Business Mailing Address
First Line	:	2767 U.S. HIGHWAY 90 WEST
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055
Country	:	US
Telephone Number	:	386-755-3136
Fax Number	:	386-755-4816

Provider Business Practice Location Address
First Line	:	2767 U.S. HIGHWAY 90 WEST
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055
Country	:	US
Telephone Number	:	386-755-3136
Fax Number	:	386-755-4816

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2023
Last Update Date	:	05/19/2023

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