Provider Demographics
NPI:1497153084
Name:COMMONWEALTH VEIN CLINIC
Entity Type:Organization
Organization Name:COMMONWEALTH VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOREST
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:804-754-6707
Mailing Address - Street 1:518 W ATLANTIC ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-1906
Mailing Address - Country:US
Mailing Address - Phone:804-754-6707
Mailing Address - Fax:
Practice Address - Street 1:518 W ATLANTIC ST
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1906
Practice Address - Country:US
Practice Address - Phone:804-754-6707
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty