Provider Demographics
NPI:1104061167
Name:RETINAPRO, PC
Entity type:Organization
Organization Name:RETINAPRO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-408-3705
Mailing Address - Street 1:440 D ST
Mailing Address - Street 2:210
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2817
Mailing Address - Country:US
Mailing Address - Phone:801-408-3705
Mailing Address - Fax:801-408-3706
Practice Address - Street 1:440 D ST
Practice Address - Street 2:210
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2817
Practice Address - Country:US
Practice Address - Phone:801-408-3705
Practice Address - Fax:801-408-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5216808-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty