Provider Demographics
NPI:1720370133
Name:PHYSICIANS VEIN CLINICS, PC
Entity Type:Organization
Organization Name:PHYSICIANS VEIN CLINICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORNELL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:605-275-6128
Mailing Address - Street 1:3401 S KELLEY AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-6300
Mailing Address - Country:US
Mailing Address - Phone:605-274-0217
Mailing Address - Fax:605-275-6398
Practice Address - Street 1:3401 S KELLEY AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-6300
Practice Address - Country:US
Practice Address - Phone:605-274-0217
Practice Address - Fax:605-275-6398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
202K00000X
SD4768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS104986Medicare PIN