Provider Demographics
NPI:1043322811
Name:LASER AND VEIN CENTER PLLC
Entity Type:Organization
Organization Name:LASER AND VEIN CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-676-8346
Mailing Address - Street 1:608 NORTHWEST BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2174
Mailing Address - Country:US
Mailing Address - Phone:208-676-8346
Mailing Address - Fax:208-664-5345
Practice Address - Street 1:608 NORTHWEST BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2174
Practice Address - Country:US
Practice Address - Phone:208-676-8346
Practice Address - Fax:208-664-5345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1379051Medicare ID - Type Unspecified