Provider Demographics
NPI:1477892172
Name:THE RETINA CENTER OF WESTERN COLORADO RLLP
Entity Type:Organization
Organization Name:THE RETINA CENTER OF WESTERN COLORADO RLLP
Other - Org Name:WILLIAM J. WATERHOUSE, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WATERHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-255-7065
Mailing Address - Street 1:2478 PATTERSON RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-3605
Mailing Address - Country:US
Mailing Address - Phone:970-255-7065
Mailing Address - Fax:970-255-7076
Practice Address - Street 1:2478 PATTERSON RD
Practice Address - Street 2:SUITE 7
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-3605
Practice Address - Country:US
Practice Address - Phone:970-255-7065
Practice Address - Fax:970-255-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-31
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01335132Medicaid
841413590001OtherROCKY MOUNTAIN HEALTH PLANS
CO841413590003OtherROCKY MOUNTAIN HEALTH PLANS
COCOA107144Medicare UPIN
COC93841Medicare UPIN