1912390097 NPI number — RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR

Table of content: (NPI 1912390097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912390097 NPI number — RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
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:
1912390097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 E CALIFORNIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91105-3205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-568-8838
Provider Business Mailing Address Fax Number:
626-574-7188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
47474 WASHINGTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA QUINTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92253-8846
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-564-2500
Provider Business Practice Location Address Fax Number:
760-564-2577
Provider Enumeration Date:
03/12/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
TOM
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
FOUNDER
Authorized Official Telephone Number:
626-568-8838

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  A69909 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , with the licence number: A69909 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760541569 . This is a "GROUP NPI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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