Provider Demographics
NPI:1114612314
Name:KRYSTAL CLEAR IMAGING LLC
Entity type:Organization
Organization Name:KRYSTAL CLEAR IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-977-4788
Mailing Address - Street 1:1529 PEPPOLI LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8775
Mailing Address - Country:US
Mailing Address - Phone:505-303-0372
Mailing Address - Fax:
Practice Address - Street 1:7007 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4450
Practice Address - Country:US
Practice Address - Phone:505-303-0372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty