Healthcare Provider Details

I. General information

NPI: 1861539694
Provider Name (Legal Business Name): RETINA CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 01/24/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11710 OLD BALLAS RD SUITE 102
SAINT LOUIS MO
63141-7076
US

IV. Provider business mailing address

11710 OLD BALLAS RD SUITE 102
SAINT LOUIS MO
63141-7076
US

V. Phone/Fax

Practice location:
  • Phone: 314-569-2020
  • Fax: 314-569-1596
Mailing address:
  • Phone: 314-569-2020
  • Fax: 314-569-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number2004012770
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberR9531
License Number StateMO

VIII. Authorized Official

Name: KIMBERLY ANN THOMPSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 314-569-2020