Provider Demographics
NPI:1255435335
Name:RETINA CONSULTANTS OF NEVADA LLP
Entity type:Organization
Organization Name:RETINA CONSULTANTS OF NEVADA LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-202-4776
Mailing Address - Street 1:2850 W HORIZON RIDGE PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4395
Mailing Address - Country:US
Mailing Address - Phone:702-202-4776
Mailing Address - Fax:
Practice Address - Street 1:3650 S POINTE CIR STE 210
Practice Address - Street 2:
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-0423
Practice Address - Country:US
Practice Address - Phone:702-369-0200
Practice Address - Fax:702-243-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVQ07000085114832207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCC6528OtherBCBS ANTHEM GRP
NV100506154Medicaid