Healthcare Provider Details

I. General information

NPI: 1760467682
Provider Name (Legal Business Name): SOUTHEAST RETINA CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3685 WHEELER RD STE 201
AUGUSTA GA
30909
US

IV. Provider business mailing address

PO BOX 11407
BIRMINGHAM AL
35246-3035
US

V. Phone/Fax

Practice location:
  • Phone: 706-650-0061
  • Fax: 706-650-0064
Mailing address:
  • Phone: 706-650-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN BECKER
Title or Position: CFO
Credential:
Phone: 706-243-2259