1306996541 NPI number — VALLEY RETINA SURGEONS LLC

Table of content: (NPI 1306996541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306996541 NPI number — VALLEY RETINA SURGEONS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VALLEY RETINA SURGEONS LLC
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:
Provider Other Organization Name Type Code:
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:
1306996541
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11977
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85318-1977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-773-3937
Provider Business Mailing Address Fax Number:
623-773-3955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20118 N 67TH AVE
Provider Second Line Business Practice Location Address:
SUITE 300-240
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85308-4621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-773-3937
Provider Business Practice Location Address Fax Number:
623-773-3955
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KIM
Authorized Official First Name:
MIN
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
623-773-3937

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  36025 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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