Provider Demographics
NPI:1144569757
Name:VEIN CARE PAVILION OF THE SOUTH
Entity Type:Organization
Organization Name:VEIN CARE PAVILION OF THE SOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-951-1998
Mailing Address - Street 1:W178N9912 RIVERCREST DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GERMANTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53022-4645
Mailing Address - Country:US
Mailing Address - Phone:262-672-6900
Mailing Address - Fax:
Practice Address - Street 1:W178N9912 RIVERCREST DR
Practice Address - Street 2:SUITE 102
Practice Address - City:GERMANTOWN
Practice Address - State:WI
Practice Address - Zip Code:53022-4645
Practice Address - Country:US
Practice Address - Phone:262-672-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44670-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty