Healthcare Provider Details

I. General information

NPI: 1174972145
Provider Name (Legal Business Name): RETINA INSTITUTE OF CA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 06/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14501 MAGNOLIA ST STE 103
WESTMINSTER CA
92683-1307
US

IV. Provider business mailing address

100 E CALIFORNIA BLVD
PASADENA CA
91105-3205
US

V. Phone/Fax

Practice location:
  • Phone: 714-594-7575
  • Fax: 714-594-7567
Mailing address:
  • Phone: 626-269-5357
  • 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 TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA69909
License Number StateCA

VIII. Authorized Official

Name: TOM S CHANG
Title or Position: OWNER
Credential: MD
Phone: 626-568-8838