Provider Demographics
NPI:1114700770
Name:MACK VEIN SPECIALISTS
Entity Type:Organization
Organization Name:MACK VEIN SPECIALISTS
Other - Org Name:GREAT BASIN VEIN SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANWAR
Authorized Official - Middle Name:SELASSIE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-744-0949
Mailing Address - Street 1:605 SIERRA ROSE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2093
Mailing Address - Country:US
Mailing Address - Phone:775-451-1730
Mailing Address - Fax:775-451-1713
Practice Address - Street 1:605 SIERRA ROSE DR STE 4
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2093
Practice Address - Country:US
Practice Address - Phone:775-451-1730
Practice Address - Fax:775-451-1713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty