1942996343 NPI number — MR VEIN

Table of content: (NPI 1942996343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942996343 NPI number — MR VEIN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MR VEIN
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:
1942996343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 391
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUENA PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90621-0391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-367-4688
Provider Business Mailing Address Fax Number:
657-452-0551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8601 ROLAND ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUENA PARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90621-4812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-367-4688
Provider Business Practice Location Address Fax Number:
657-452-0551
Provider Enumeration Date:
04/18/2023

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNS
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
714-367-4688

Provider Taxonomy Codes

  • Taxonomy code: 246RP1900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1295495737 . This is a "NURSE PRACTITONER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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