Provider Demographics
NPI:1255603247
Name:GRAND VEIN SPECIALISTS LLC
Entity type:Organization
Organization Name:GRAND VEIN SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAVIER
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-942-6141
Mailing Address - Street 1:4952 W IRVING PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2693
Mailing Address - Country:US
Mailing Address - Phone:773-942-6141
Mailing Address - Fax:866-707-2267
Practice Address - Street 1:4952 W IRVING PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2693
Practice Address - Country:US
Practice Address - Phone:773-942-6141
Practice Address - Fax:866-707-2267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-116087202K00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Multi-Specialty