Provider Demographics
NPI:1689807232
Name:SPECIALTY RETINA CENTER, LLC
Entity Type:Organization
Organization Name:SPECIALTY RETINA CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHATINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-322-3588
Mailing Address - Street 1:2001 W SAMPLE RD STE 320
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-1346
Mailing Address - Country:US
Mailing Address - Phone:561-322-3588
Mailing Address - Fax:754-812-5993
Practice Address - Street 1:2001 W SAMPLE RD STE 320
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-1346
Practice Address - Country:US
Practice Address - Phone:561-322-3588
Practice Address - Fax:754-812-5993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 81086207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty