Provider Demographics
NPI:1821181850
Name:VITREO-RETINAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:VITREO-RETINAL MEDICAL GROUP, INC.
Other - Org Name:RETINAL CONSULTANTS MEDICAL GROUP, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MENTINK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-453-5450
Mailing Address - Street 1:3939 J ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3631
Mailing Address - Country:US
Mailing Address - Phone:916-454-6191
Mailing Address - Fax:916-454-1036
Practice Address - Street 1:3939 J ST STE 106
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3631
Practice Address - Country:US
Practice Address - Phone:916-454-4861
Practice Address - Fax:916-454-3603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0030320Medicaid
CAZZZ82386ZOtherBLUE SHIELD CA
WA0199873OtherSAC. -DEPT. OF LABOR WA
CACP5300OtherSAC. OFFICE -RAILROAD MED
CAZZZ82386ZMedicare ID - Type UnspecifiedSACRAMENTO OFFICE
CACP5300OtherSAC. OFFICE -RAILROAD MED