Healthcare Provider Details

I. General information

NPI: 1770976987
Provider Name (Legal Business Name): RETINA INSTITUTE OF CALIFORNIA MEDICAL GROUP, A CALIFORNIA MEDICAL PAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2015
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6906 BROCKTON AVE STE. 6
RIVERSIDE CA
92506-4090
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 951-784-8373
  • Fax: 951-784-8377
Mailing address:
  • Phone: 626-568-8838
  • Fax: 626-574-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberA69909
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA69909
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TOM S CHANG
Title or Position: FOUNDER
Credential:
Phone: 626-568-8838