Healthcare Provider Details

I. General information

NPI: 1679641203
Provider Name (Legal Business Name): LAURIE CHALKIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 CASTRO VALLEY BLVD
CASTRO VALLEY CA
94546-4405
US

IV. Provider business mailing address

3717 CASTRO VALLEY BLVD
CASTRO VALLEY CA
94546-4405
US

V. Phone/Fax

Practice location:
  • Phone: 510-538-3937
  • Fax:
Mailing address:
  • Phone: 510-538-3937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number7597
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number10195
License Number StateCA

VIII. Authorized Official

Name: MS. LAURIE RUTH CHAIKIN
Title or Position: OPTOMETRIST OWNER
Credential: O.D.
Phone: 510-538-3937