Provider Demographics
NPI:1891852562
Name:CENTRAL VALLEY VEIN AND LASER CENTER, A MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTRAL VALLEY VEIN AND LASER CENTER, A MEDICAL GROUP
Other - Org Name:ELMORE MEDICAL VEIN & LASER TREATMENT CENTER, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-435-0717
Mailing Address - Street 1:7131 N 11TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3375
Mailing Address - Country:US
Mailing Address - Phone:559-435-0717
Mailing Address - Fax:559-435-9105
Practice Address - Street 1:7131 N 11TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3375
Practice Address - Country:US
Practice Address - Phone:559-435-0717
Practice Address - Fax:559-435-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C372670208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID#
CAA36556Medicare UPIN
CA00C372670Medicare ID - Type Unspecified