1003216649 NPI number — TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, 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 1003216649 NPI number — TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, 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:
6
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:
1003216649
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1106 ALSTON AVE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-4644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-698-8346
Provider Business Mailing Address Fax Number:
817-698-9933

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1106 ALSTON AVE
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-698-8346
Provider Business Practice Location Address Fax Number:
817-698-9933
Provider Enumeration Date:
09/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HOLTMAN
Authorized Official First Name:
COREY
Authorized Official Middle Name:
T
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
817-698-8346

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  801678647 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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