1750397014 NPI number — RETINA CENTER OF GUAM, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750397014 NPI number — RETINA CENTER OF GUAM, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA CENTER OF GUAM, 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:
1750397014
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:
2055 N KING ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HONOLULU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96819-3462
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-533-7400
Provider Business Mailing Address Fax Number:
808-521-7798

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
RETINA CENTER OF GUAM, LLC
Provider Second Line Business Practice Location Address:
633 GOVERNOR CARLOS CAMACHO RD, SUITE 205
Provider Business Practice Location Address City Name:
TAMUNING
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-533-7400
Provider Business Practice Location Address Fax Number:
808-521-7798
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PANG
Authorized Official First Name:
M. PIERRE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
808-533-7400

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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