Provider Demographics
NPI:1245658988
Name:GLENDALE VEIN CLINIC, PC
Entity type:Organization
Organization Name:GLENDALE VEIN CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FLORA
Authorized Official - Middle Name:
Authorized Official - Last Name:KATSNELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-305-8460
Mailing Address - Street 1:PO BOX 832
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0832
Mailing Address - Country:US
Mailing Address - Phone:847-593-8460
Mailing Address - Fax:
Practice Address - Street 1:801 S CHEVY CHASE DR
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-4431
Practice Address - Country:US
Practice Address - Phone:323-798-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-31
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty