1760733448 NPI number — TRUFFLES VEIN CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760733448 NPI number — TRUFFLES VEIN CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRUFFLES VEIN CENTER, LLC
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:
1760733448
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
874 LANIER AVE W STE 220
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30214-7659
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-833-1444
Provider Business Mailing Address Fax Number:
678-833-1445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
874 LANIER AVE W
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30214-7662
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-833-1444
Provider Business Practice Location Address Fax Number:
678-833-1409
Provider Enumeration Date:
09/21/2012

Additional Information

Authorized Official

Authorized Official Last Name:
FELDMAN
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-833-1444

Provider Taxonomy Codes

  • Taxonomy code: 208200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 24BCBRW . This is a "MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000580423A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com