Provider Demographics
NPI:1346539095
Name:BEN PALMER, O.D. A PROFESSIONAL OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:BEN PALMER, O.D. A PROFESSIONAL OPTOMETRIC CORPORATION
Other - Org Name:NIPOMO OPTOMETRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-929-1982
Mailing Address - Street 1:125 S FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-8979
Mailing Address - Country:US
Mailing Address - Phone:805-929-1982
Mailing Address - Fax:805-929-5052
Practice Address - Street 1:125 S FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-8979
Practice Address - Country:US
Practice Address - Phone:805-929-1982
Practice Address - Fax:805-929-5052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13794 TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFI860AMedicare PIN