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General NPI Number Information
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NPI Number | 1174972145
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Entity Type | Organization
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Legal Business Name | RETINA INSTITUTE OF CA
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Dates
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Enumeration Date | 06/09/2016
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Last Update Date | 06/09/2016
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Provider Practice Location Address
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Address Line | 14501 MAGNOLIA ST STE 103
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City | WESTMINSTER
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State | CA
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Zip | 92683-1307
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Country | US
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Telephone | 714-594-7575
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Fax | 714-594-7567
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Provider Business Mailing Address
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Address Line | 100 E CALIFORNIA BLVD
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City | PASADENA
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State | CA
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Zip | 91105-3205
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Country | US
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Telephone | 626-269-5357
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Fax | 626-574-7188
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Authorized Official
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Title or Position | OWNER
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Name | TOM S CHANG
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Credential | MD
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Telephone | 626-568-8838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | A69909
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | A69909
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License Number State | CA
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