Provider Demographics
NPI:1720480007
Name:CRYSTAL VISION CLINIC PA
Entity type:Organization
Organization Name:CRYSTAL VISION CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ENDRES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:763-537-3213
Mailing Address - Street 1:5730 BOTTINEAU BLVD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-3181
Mailing Address - Country:US
Mailing Address - Phone:763-537-3213
Mailing Address - Fax:
Practice Address - Street 1:5730 BOTTINEAU BLVD.
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-3104
Practice Address - Country:US
Practice Address - Phone:763-537-3213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-18
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty