Provider Demographics
NPI:1902983778
Name:CRYSTAL VISION OPTICAL INC.
Entity Type:Organization
Organization Name:CRYSTAL VISION OPTICAL INC.
Other - Org Name:GOLDEN GATE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:SITTO
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC, COT
Authorized Official - Phone:248-689-0213
Mailing Address - Street 1:2943 E BIG BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2467
Mailing Address - Country:US
Mailing Address - Phone:248-689-0213
Mailing Address - Fax:
Practice Address - Street 1:2943 E BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2467
Practice Address - Country:US
Practice Address - Phone:248-689-0213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002152152W00000X
MI4901002898152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4855083Medicaid
MI0P29860Medicare ID - Type Unspecified
MI4855083Medicaid
MIU35796Medicare UPIN
MIP29860001Medicare ID - Type UnspecifiedO.D.
MIP29860002Medicare PIN