MEDICARE: VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WL0500X	Low Vision Rehabilitation Optometrist	220000439	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

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

Provider Business Mailing Address
First Line	:	2500 EL CAMINO REAL STE 100
Second Line	:
City	:	PALO ALTO
State	:	CA
Zip	:	94306-1723
Country	:	US
Telephone Number	:	650-858-0202
Fax Number	:	650-858-0214

Provider Business Practice Location Address
First Line	:	3315 MISSION DR STE B
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95065
Country	:	US
Telephone Number	:	831-458-9766
Fax Number	:	831-426-6233

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. KARAE LISLE
Credential	:
Telephone Number	:	650-858-0202

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	12/18/2018

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Directions to “VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED ” Practice Location

Language	Start Address	Practice Location

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