1255896544 NPI number — MODERN VASCULAR OF TUCSON, LLC

Table of content: (NPI 1255896544)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255896544 NPI number — MODERN VASCULAR OF TUCSON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN VASCULAR OF TUCSON, 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:
1255896544
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/31/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
26500 AGOURA RD STE 102-587
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALABASAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91302-1952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-880-8605
Provider Business Mailing Address Fax Number:
818-579-7916

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2171 W ORANGE GROVE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85741-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-201-4980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/31/2019

Additional Information

Authorized Official

Authorized Official Last Name:
GAMPEL
Authorized Official First Name:
YURY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
818-880-8605

Provider Taxonomy Codes

  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2471V0106X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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