1306917943 NPI number — VEIN RESTORATION GROUP, INC.

Table of content: (NPI 1306917943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306917943 NPI number — VEIN RESTORATION GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VEIN RESTORATION GROUP, INC.
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:
TOTAL LEG CARE
Provider Other Organization Name Type Code:
3
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:
1306917943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 865028
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75086-5028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-964-5347
Provider Business Mailing Address Fax Number:
972-599-1853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2828 W PARKER RD
Provider Second Line Business Practice Location Address:
SUITE B106F
Provider Business Practice Location Address City Name:
PLANO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75075-9153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-964-5347
Provider Business Practice Location Address Fax Number:
972-599-1853
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TESORIERO
Authorized Official First Name:
ALBERT
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT CEO
Authorized Official Telephone Number:
972-964-5347

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0090PG . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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