1760733448 NPI number — TRUFFLES VEIN CENTER, LLC

Table of content: (NPI 1760733448)

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".




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