Provider Demographics
NPI:1376989921
Name:RETINA TREATMENT CENTER, P.L.
Entity Type:Organization
Organization Name:RETINA TREATMENT CENTER, P.L.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSCOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-870-2120
Mailing Address - Street 1:1911 MANATEE AVE E
Mailing Address - Street 2:STE 101
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1562
Mailing Address - Country:US
Mailing Address - Phone:941-870-2120
Mailing Address - Fax:941-328-3595
Practice Address - Street 1:1911 MANATEE AVE E
Practice Address - Street 2:STE 101
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1562
Practice Address - Country:US
Practice Address - Phone:941-870-2120
Practice Address - Fax:941-328-3595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64743207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty