Provider Demographics
NPI:1942067723
Name:EVERGREEN RETINA INC A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:EVERGREEN RETINA INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-455-7797
Mailing Address - Street 1:27335 TOURNEY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-2205
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27335 TOURNEY RD STE 210
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-2205
Practice Address - Country:US
Practice Address - Phone:661-455-7797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-28
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty