Healthcare Provider Details

I. General information

NPI: 1255388765
Provider Name (Legal Business Name): VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 MISSION DR STE B
SANTA CRUZ CA
95065
US

IV. Provider business mailing address

2500 EL CAMINO REAL STE 100
PALO ALTO CA
94306-1723
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-9766
  • Fax: 831-426-6233
Mailing address:
  • Phone: 650-858-0202
  • Fax: 650-858-0214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number220000439
License Number StateCA

VIII. Authorized Official

Name: MS. KARAE LISLE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 650-858-0202