1265575591 NPI number — CALIFORNIA RETINA CONSULTANTS

Table of content: (NPI 1265575591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265575591 NPI number — CALIFORNIA RETINA CONSULTANTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CALIFORNIA RETINA CONSULTANTS
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:
1265575591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 E MICHELTORENA ST
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93103-2254
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-963-1648
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
SANTA MARIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93454-4825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-922-2068
Provider Business Practice Location Address Fax Number:
805-880-5915
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
AVERY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
805-963-1648

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0107X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ60752Z . This is a "BLUE SHIELD GROUP #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0091151 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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