Healthcare Provider Details

I. General information

NPI: 1952454142
Provider Name (Legal Business Name): RETINA ASSOCIATES, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1536 STORY AVE
LOUISVILLE KY
40206-1738
US

IV. Provider business mailing address

1536 STORY AVE
LOUISVILLE KY
40206-1738
US

V. Phone/Fax

Practice location:
  • Phone: 502-589-1500
  • Fax: 502-589-1556
Mailing address:
  • Phone: 502-589-1500
  • Fax: 502-589-1556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK M PRUSSIAN
Title or Position: ADMINISTRATOR
Credential: CEO
Phone: 502-589-1500