Provider Demographics
NPI:1124218920
Name:VEIN CENTER MD, LLC
Entity Type:Organization
Organization Name:VEIN CENTER MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:SHEPPARD
Authorized Official - Last Name:FUNDERBURK
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:803-534-6550
Mailing Address - Street 1:870 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4831
Mailing Address - Country:US
Mailing Address - Phone:803-534-6550
Mailing Address - Fax:
Practice Address - Street 1:870 HOLLY ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4831
Practice Address - Country:US
Practice Address - Phone:803-534-6550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2007-0000207261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty