1255025078 NPI number — USA VEIN CLINICS OF MISSISSIPPI LLC

Table of content: (NPI 1255025078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255025078 NPI number — USA VEIN CLINICS OF MISSISSIPPI LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
USA VEIN CLINICS OF MISSISSIPPI 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:
1255025078
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 791
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORTHBROOK
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60065-0791
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7900 AIRWAYS BLVD # A
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
SOUTHAVEN
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38671-4117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-593-8460
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2023

Additional Information

Authorized Official

Authorized Official Last Name:
KATSNELSON
Authorized Official First Name:
YAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
847-774-5300

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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