Provider Demographics
NPI:1346896982
Name:PALESTINE VASCULAR LAB, LLC
Entity Type:Organization
Organization Name:PALESTINE VASCULAR LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTONDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-539-7477
Mailing Address - Street 1:300 WILLOW CREEK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4433
Mailing Address - Country:US
Mailing Address - Phone:903-729-2888
Mailing Address - Fax:903-729-2781
Practice Address - Street 1:300 WILLOW CREEK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4433
Practice Address - Country:US
Practice Address - Phone:903-729-2888
Practice Address - Fax:903-729-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-09
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty