Provider Demographics
NPI:1174735963
Name:STANFORD OPTICAL SHOP
Entity type:Organization
Organization Name:STANFORD OPTICAL SHOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:REGALADO
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:650-736-0566
Mailing Address - Street 1:900 BLAKE WILBUR DR.
Mailing Address - Street 2:ROOM W1090
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1185
Mailing Address - Country:US
Mailing Address - Phone:650-736-0566
Mailing Address - Fax:650-736-0575
Practice Address - Street 1:900 BLAKE WILBUR DR RM W1090
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2201
Practice Address - Country:US
Practice Address - Phone:650-736-0566
Practice Address - Fax:650-736-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL 4881156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty