Provider Demographics
NPI:1922256072
Name:ELITE ANTI-AGING AND VEIN CLINIC
Entity Type:Organization
Organization Name:ELITE ANTI-AGING AND VEIN CLINIC
Other - Org Name:ELITE VEIN CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-453-0017
Mailing Address - Street 1:PO BOX 901480
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64190-1480
Mailing Address - Country:US
Mailing Address - Phone:816-453-0017
Mailing Address - Fax:816-453-0018
Practice Address - Street 1:5400 N OAK TRFY
Practice Address - Street 2:SUITE 115
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4688
Practice Address - Country:US
Practice Address - Phone:816-453-0017
Practice Address - Fax:816-453-0018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007030787261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical