1215189360 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Table of content: (NPI 1215189360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215189360 NPI number — VITREO-RETINAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITREO-RETINAL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RETINA CENTER OF GRASS VALLEY, INC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215189360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 PARK CENTER DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95825-8341
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-596-2027
Provider Business Mailing Address Fax Number:
866-913-6557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 SIERRA COLLEGE DR
Provider Second Line Business Practice Location Address:
SUITE 265
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-5082
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-273-8062
Provider Business Practice Location Address Fax Number:
916-454-3603
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
PEARLMAN
Authorized Official First Name:
JOEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
916-596-2027

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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