Provider Demographics
NPI:1669588455
Name:THE VEIN AND LASER CENTER OF NORTHERN COLORADO, LLC
Entity type:Organization
Organization Name:THE VEIN AND LASER CENTER OF NORTHERN COLORADO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-482-6456
Mailing Address - Street 1:2008 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4325
Mailing Address - Country:US
Mailing Address - Phone:970-484-4757
Mailing Address - Fax:970-484-4759
Practice Address - Street 1:1915 WILMINGTON DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80528-6299
Practice Address - Country:US
Practice Address - Phone:970-372-0534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC807023Medicare PIN