Provider Demographics
NPI:1376662312
Name:COSMETIC VEIN CENTER, LLC
Entity Type:Organization
Organization Name:COSMETIC VEIN CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:FRANCES
Authorized Official - Last Name:CHUBACK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:201-445-8820
Mailing Address - Street 1:265 ACKERMAN AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-0745
Mailing Address - Country:US
Mailing Address - Phone:201-445-8820
Mailing Address - Fax:201-445-8850
Practice Address - Street 1:265 ACKERMAN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4200
Practice Address - Country:US
Practice Address - Phone:201-445-8820
Practice Address - Fax:201-445-8850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2007-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ091886Medicare PIN