Provider Demographics
NPI:1811126055
Name:ABUNDANT LIFE VEIN CENTERS LLC
Entity type:Organization
Organization Name:ABUNDANT LIFE VEIN CENTERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:515-223-0592
Mailing Address - Street 1:1300 37TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1900
Mailing Address - Country:US
Mailing Address - Phone:515-223-0592
Mailing Address - Fax:515-223-8316
Practice Address - Street 1:1300 37TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1900
Practice Address - Country:US
Practice Address - Phone:515-223-0592
Practice Address - Fax:515-223-8316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA2086S0129X302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization