Provider Demographics
NPI:1235371360
Name:LASER VEIN CENTER OF FAIRBANKS, LLC
Entity Type:Organization
Organization Name:LASER VEIN CENTER OF FAIRBANKS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:IVES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-452-8346
Mailing Address - Street 1:PO BOX 440
Mailing Address - Street 2:
Mailing Address - City:ESTER
Mailing Address - State:AK
Mailing Address - Zip Code:99725-0440
Mailing Address - Country:US
Mailing Address - Phone:907-452-8346
Mailing Address - Fax:907-451-8346
Practice Address - Street 1:506 GAFFNEY RD
Practice Address - Street 2:SUITE 300
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4914
Practice Address - Country:US
Practice Address - Phone:907-452-8346
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty