Healthcare Provider Details

I. General information

NPI: 1013249986
Provider Name (Legal Business Name): EARLE BAUM CENTER OF THE BLIND INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 OCCIDENTAL RD
SANTA ROSA CA
95401-5635
US

IV. Provider business mailing address

4539 OCCIDENTAL RD
SANTA ROSA CA
95401-5635
US

V. Phone/Fax

Practice location:
  • Phone: 707-523-3222
  • Fax: 707-636-2768
Mailing address:
  • Phone: 707-523-3222
  • Fax: 707-636-2768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number8817T
License Number StateCA

VIII. Authorized Official

Name: MR. ALLAN BRENNER
Title or Position: PRESIDENT/CEO
Credential:
Phone: 707-523-3222