Provider Demographics
NPI:1659313997
Name:SOUTHERN CALIFORNIA DESERT RETINA CONSULTANTS
Entity Type:Organization
Organization Name:SOUTHERN CALIFORNIA DESERT RETINA CONSULTANTS
Other - Org Name:INLAND RETINA CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR
Authorized Official - Phone:760-340-2394
Mailing Address - Street 1:36949 COOK ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-6080
Mailing Address - Country:US
Mailing Address - Phone:760-340-2394
Mailing Address - Fax:760-340-2369
Practice Address - Street 1:36949 COOK ST STE 101
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-6080
Practice Address - Country:US
Practice Address - Phone:760-340-2394
Practice Address - Fax:760-340-2369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0069070Medicaid
CAGR0069073Medicaid
CAGR0069072Medicaid
CAGR0069070Medicaid
CAGR0069073Medicaid
CAZZZ70254ZMedicare PIN