Provider Demographics
NPI:1720620313
Name:RETINA LABS (USA), INC.
Entity Type:Organization
Organization Name:RETINA LABS (USA), INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JANISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-344-2692
Mailing Address - Street 1:555 MARRIOTT DR STE 315
Mailing Address - Street 2:SUITE 315
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-5088
Mailing Address - Country:US
Mailing Address - Phone:866-344-2692
Mailing Address - Fax:866-214-0724
Practice Address - Street 1:555 MARRIOTT DR STE 315
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-5088
Practice Address - Country:US
Practice Address - Phone:866-344-2692
Practice Address - Fax:866-214-0724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-15
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ059898Medicaid