Provider Demographics
NPI:1720391527
Name:PREMIER VEIN CARE
Entity Type:Organization
Organization Name:PREMIER VEIN CARE
Other - Org Name:PREMIER VEIN CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-540-3333
Mailing Address - Street 1:3231 S HIGUERA ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6924
Mailing Address - Country:US
Mailing Address - Phone:805-540-3333
Mailing Address - Fax:805-540-3344
Practice Address - Street 1:3231 S HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6924
Practice Address - Country:US
Practice Address - Phone:805-540-3333
Practice Address - Fax:805-540-3344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64552YOtherBLUE SHIELD PROVIDER NUMBER
CADQ8118Medicare PIN
CAZZZ64552YOtherBLUE SHIELD PROVIDER NUMBER