Provider Demographics
NPI:1124206073
Name:BIG COUNTRY VEIN RELIEF LP
Entity Type:Organization
Organization Name:BIG COUNTRY VEIN RELIEF LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOM
Authorized Official - Prefix:
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GAULDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-647-4397
Mailing Address - Street 1:4716 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-4733
Mailing Address - Country:US
Mailing Address - Phone:325-795-1200
Mailing Address - Fax:
Practice Address - Street 1:109 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-5917
Practice Address - Country:US
Practice Address - Phone:325-643-3300
Practice Address - Fax:325-641-8714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-02
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0084NJOtherBCBS
TX00W249Medicare PIN