Provider Demographics
NPI:1376693887
Name:SOUTHEAST VEIN & LASER CENTER, P.C.
Entity Type:Organization
Organization Name:SOUTHEAST VEIN & LASER CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:TODD
Authorized Official - Suffix:III
Authorized Official - Credentials:MD, FACPH
Authorized Official - Phone:334-678-9494
Mailing Address - Street 1:3280 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-3040
Mailing Address - Country:US
Mailing Address - Phone:334-678-9494
Mailing Address - Fax:334-678-8878
Practice Address - Street 1:3280 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-3040
Practice Address - Country:US
Practice Address - Phone:334-678-9494
Practice Address - Fax:334-678-8878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL15348174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty