1104229855 NPI number — RETINA CENTER OF OHIO, LLC

Table of content: (NPI 1104229855)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104229855 NPI number — RETINA CENTER OF OHIO, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA CENTER OF OHIO, 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:
1104229855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1611 S GREEN RD
Provider Second Line Business Mailing Address:
SUITE 306B
Provider Business Mailing Address City Name:
SOUTH EUCLID
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44121-4129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-382-3366
Provider Business Mailing Address Fax Number:
216-382-4959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1161 S. GREEN ROAD
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
SOUTH EUCLID
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44121-4129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-382-3366
Provider Business Practice Location Address Fax Number:
216-382-4959
Provider Enumeration Date:
10/08/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PIETROPINTO
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
216-382-3366

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)

  • Identifier: 0806837 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 21874635700 . This is a "WORKMAN'S COMP" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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