Healthcare Provider Details

I. General information

NPI: 1861187403
Provider Name (Legal Business Name): PENINSULA OPTICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/14/2023
Certification Date: 04/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 UNIVERSITY AVE
PALO ALTO CA
94301-1813
US

IV. Provider business mailing address

112 SURREY CT
MILPITAS CA
95035-5018
US

V. Phone/Fax

Practice location:
  • Phone: 650-326-8415
  • Fax: 650-326-8417
Mailing address:
  • Phone: 669-237-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XL0004X
TaxonomyLow Vision Occupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MALINA KINDT
Title or Position: CFO / MANAGING MEMBER
Credential:
Phone: 669-237-8380