Healthcare Provider Details

I. General information

NPI: 1316816416
Provider Name (Legal Business Name): LIGHTHOUSE FOR THE BLIND AND VISUALLY IMPAIRED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2025
Last Update Date: 11/05/2025
Certification Date: 11/05/2025
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: 415-694-7330
Mailing address:
  • Phone: 707-523-3222
  • Fax: 415-694-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM BRANDON COX
Title or Position: INTERIM CEO / CHIEF OPERATING OFFIC
Credential:
Phone: 415-694-7347