Provider Demographics
NPI:1215411970
Name:CENTER FOR VEIN RESTORATION AZ LLC
Entity Type:Organization
Organization Name:CENTER FOR VEIN RESTORATION AZ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-254-1761
Mailing Address - Street 1:7474 GREENWAY CENTER DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3500
Mailing Address - Country:US
Mailing Address - Phone:815-254-1761
Mailing Address - Fax:815-254-5431
Practice Address - Street 1:1500 S DOBSON RD STE 310
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4751
Practice Address - Country:US
Practice Address - Phone:855-830-8346
Practice Address - Fax:240-473-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty