Healthcare Provider Details

I. General information

NPI: 1942067723
Provider Name (Legal Business Name): EVERGREEN RETINA INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2024
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27335 TOURNEY RD STE 210
VALENCIA CA
91355-2205
US

IV. Provider business mailing address

27335 TOURNEY RD STE 210
VALENCIA CA
91355-2205
US

V. Phone/Fax

Practice location:
  • Phone: 661-455-7797
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIA SEIN
Title or Position: OWNER
Credential: MD
Phone: 661-455-7797