Healthcare Provider Details

I. General information

NPI: 1912419227
Provider Name (Legal Business Name): SOUTHERN RETINAL INSTITUTE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 VETERANS MEMORIAL BLVD STE 160
METAIRIE LA
70002-6175
US

IV. Provider business mailing address

2800 VETERANS MEMORIAL BLVD STE 160
METAIRIE LA
70002-6175
US

V. Phone/Fax

Practice location:
  • Phone: 504-264-9428
  • Fax: 504-264-9438
Mailing address:
  • Phone: 504-264-9472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number202072
License Number StateLA

VIII. Authorized Official

Name: MRS. RHONDA GARRISON
Title or Position: CREDENTIALING COORDINATOR
Credential: CREDENTIALING
Phone: 865-584-2127