1114912698 NPI number — FORTUNE VEIN CLINIC

Table of content: (NPI 1114912698)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114912698 NPI number — FORTUNE VEIN CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORTUNE VEIN CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114912698
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7125 E LINCOLN DR
Provider Second Line Business Mailing Address:
SUITE B109
Provider Business Mailing Address City Name:
SCOTTSDALE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85253-4429
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-991-2100
Provider Business Mailing Address Fax Number:
480-991-2102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7125 E LINCOLN DR
Provider Second Line Business Practice Location Address:
SUITE B109
Provider Business Practice Location Address City Name:
SCOTTSDALE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85253-4429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-991-2100
Provider Business Practice Location Address Fax Number:
480-991-2102
Provider Enumeration Date:
09/12/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FORTUNE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
LLOYD
Authorized Official Title or Position:
MANAGING EMPLOYEE
Authorized Official Telephone Number:
480-991-2100

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  13540 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)