Provider Demographics
NPI:1265615207
Name:VEIN & ESTHETIC CENTRE, LLC
Entity type:Organization
Organization Name:VEIN & ESTHETIC CENTRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CRITCHLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-651-1882
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-651-1882
Mailing Address - Fax:573-334-5302
Practice Address - Street 1:3065 WILLIAM ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-651-1882
Practice Address - Fax:573-334-5302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR66052086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========OtherEMPLOYER ID
MO000015590Medicare PIN