Provider Demographics
NPI:1457685398
Name:ROCKY MOUNTAIN VEIN INSTITUTE PROFESSIONAL LLC
Entity Type:Organization
Organization Name:ROCKY MOUNTAIN VEIN INSTITUTE PROFESSIONAL LLC
Other - Org Name:AMERICAN VEIN & VASCULAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:FABING
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-543-8346
Mailing Address - Street 1:PO BOX 7702
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0702
Mailing Address - Country:US
Mailing Address - Phone:970-663-2742
Mailing Address - Fax:970-342-2093
Practice Address - Street 1:115 E RIVERWALK UNIT 200
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-3320
Practice Address - Country:US
Practice Address - Phone:719-543-8346
Practice Address - Fax:719-545-1829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO450042085R0204X
2085R0204X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty