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NPI Code Detail

MEDICARE: RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP

MEDICARE: RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1152W00000XOptometristA69909CA
2174400000XSpecialistA69909CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11760541569OTHERCAGROUP NPI

General Provider Information

NPI Number : 1982097044
Entity Type Code : Organization
Provider Name (Legal Business Name) : RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP
Provider Business Mailing Address
First Line : 100 E CALIFORNIA BLVD
Second Line :
City : PASADENA
State : CA
Zip : 91105-3205
Country : US
Telephone Number : 626-568-8838
Fax Number : 626-574-7188
Provider Business Practice Location Address
First Line : 17833 COLIMA RD
Second Line :
City : CITY OF INDUSTRY
State : CA
Zip : 91748-1729
Country : US
Telephone Number : 626-965-8895
Fax Number : 626-965-8876
Authorized Official
Title or Position : FOUNDER
Name : DR. TOM S CHANG
Credential : MD
Telephone Number : 626-568-8838
Provider Enumeration Date : 03/13/2015
Last Update Date : 03/13/2015

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