Provider Demographics
NPI:1922073030
Name:RETINA VITREOUS ASSOCIATES INC
Entity Type:Organization
Organization Name:RETINA VITREOUS ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KALUCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-517-6599
Mailing Address - Street 1:6591 W CENTRAL AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43617-1087
Mailing Address - Country:US
Mailing Address - Phone:419-517-6599
Mailing Address - Fax:419-517-0503
Practice Address - Street 1:2865 N REYNOLDS RD
Practice Address - Street 2:SUITE 230
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2068
Practice Address - Country:US
Practice Address - Phone:419-578-4367
Practice Address - Fax:419-537-5639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0384936Medicaid
OH0384936Medicaid
OH9919831Medicare PIN