Provider Demographics
NPI:1275205809
Name:ADVANCED VASCULAR AND VEIN ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ADVANCED VASCULAR AND VEIN ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LACHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-208-4437
Mailing Address - Street 1:4436 MANGUM DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-2113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4436 MANGUM DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-2113
Practice Address - Country:US
Practice Address - Phone:601-919-0972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-01
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty