Provider Demographics
NPI:1003216649
Name:TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, LLC
Entity Type:Organization
Organization Name:TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, LLC
Other - Org Name:GATEWAY VEIN & LEG CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:T
Authorized Official - Last Name:HOLTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-698-8346
Mailing Address - Street 1:1106 ALSTON AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4644
Mailing Address - Country:US
Mailing Address - Phone:817-698-8346
Mailing Address - Fax:817-698-9933
Practice Address - Street 1:1106 ALSTON AVE
Practice Address - Street 2:STE 200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4644
Practice Address - Country:US
Practice Address - Phone:817-698-8346
Practice Address - Fax:817-698-9933
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TEXAS VARICOSE VEIN CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX801678647261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain