Provider Demographics
NPI:1255388765
Name:VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED
Entity type:Organization
Organization Name:VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KARAE
Authorized Official - Middle Name:
Authorized Official - Last Name:LISLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-858-0202
Mailing Address - Street 1:2500 EL CAMINO REAL STE 100
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-1723
Mailing Address - Country:US
Mailing Address - Phone:650-858-0202
Mailing Address - Fax:650-858-0214
Practice Address - Street 1:3315 MISSION DR STE B
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065
Practice Address - Country:US
Practice Address - Phone:831-458-9766
Practice Address - Fax:831-426-6233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISTA CENTER FOR THE BLIND AND VISUALLY IMPAIRED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000439152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMM70249FMedicaid
CAZZZ18872ZMedicare ID - Type Unspecified