Healthcare Provider Details

I. General information

NPI: 1346539095
Provider Name (Legal Business Name): BEN PALMER, O.D. A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2011
Last Update Date: 12/21/2024
Certification Date: 12/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S MARY AVE STE 4
NIPOMO CA
93444-7821
US

IV. Provider business mailing address

150 S MARY AVE STE 4
NIPOMO CA
93444-7821
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-1982
  • Fax: 805-929-5052
Mailing address:
  • Phone: 805-929-1982
  • Fax: 805-929-5052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13794 TLG
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BEN C PALMER
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 805-929-1982