1447208103 NPI number — VENOUS LASER CENTER OF EAST TEXAS

Table of content: (NPI 1447208103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447208103 NPI number — VENOUS LASER CENTER OF EAST TEXAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VENOUS LASER CENTER OF EAST TEXAS
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:
1447208103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1602 PINE TREE RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75604-3273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-759-8886
Provider Business Mailing Address Fax Number:
903-247-0222

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
903 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601-5416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-753-6500
Provider Business Practice Location Address Fax Number:
903-247-0222
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEATON
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-753-6500

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0049MU . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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