Provider Demographics
NPI:1831823921
Name:THIRD COAST RETINA S.C.
Entity type:Organization
Organization Name:THIRD COAST RETINA S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:262-420-5888
Mailing Address - Street 1:5017 GREEN BAY RD STE 148
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1782
Mailing Address - Country:US
Mailing Address - Phone:336-692-3384
Mailing Address - Fax:
Practice Address - Street 1:5017 GREEN BAY RD STE 148
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1782
Practice Address - Country:US
Practice Address - Phone:262-420-5888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-13
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty