Provider Demographics
NPI:1255644969
Name:FLORIDA ENDOVASCULAR SPECIALISTS LLC
Entity type:Organization
Organization Name:FLORIDA ENDOVASCULAR SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:FALCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-274-7118
Mailing Address - Street 1:1673 MASON AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5515
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:1890 LPGA BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7130
Practice Address - Country:US
Practice Address - Phone:386-274-7250
Practice Address - Fax:386-274-7259
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RADIOLOGY ASSOCIATES PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000NNOtherBLUE CROSS BLUE SHIELD OF FLORIDA