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General NPI Number Information
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NPI Number | 1821271248
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Entity Type | Organization
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Legal Business Name | RETINA SPECIALISTS OF THE CENTRAL COAST INC
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Dates
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Enumeration Date | 12/07/2007
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Last Update Date | 11/18/2009
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Provider Practice Location Address
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Address Line | 628 CALIFORNIA BLVD SUITE C
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2542
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Country | US
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Telephone | 805-547-2090
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Fax | 805-547-2095
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Provider Business Mailing Address
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Address Line | 628 CALIFORNIA BLVD SUITE C
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-2542
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Country | US
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Telephone | 805-547-2090
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Fax | 805-547-2095
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Authorized Official
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Title or Position | PRESIDENT
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Name | DEREK B. LAURITZEN
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Credential | M.D.
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Telephone | 805-547-2090
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | C3049777
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License Number State | CA
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