Healthcare Provider Details

I. General information

NPI: 1205892783
Provider Name (Legal Business Name): CAROLINA RETINA CENTER P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7620 TRENHOLM ROAD EXT
COLUMBIA SC
29223-1718
US

IV. Provider business mailing address

7620 TRENHOLM ROAD EXT
COLUMBIA SC
29223-1718
US

V. Phone/Fax

Practice location:
  • Phone: 803-736-7200
  • Fax: 803-736-2116
Mailing address:
  • Phone: 803-736-7200
  • Fax: 803-736-2116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JEFFREY GLENN GROSS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 803-736-7200