Basic Information
| Provider Information | |||||||||
| NPI: | 1124550421 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR VEIN RESTORATION FL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR | ||||||||
| Address2: | SUITE 1000 | ||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152541761 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15800 PINES BLVD | ||||||||
| Address2: | SUITE 3038 | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330271212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2017 | ||||||||
| LastUpdateDate: | 03/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | LAKHANPAL | ||||||||
| AuthorizedOfficialFirstName: | SANJIV | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8152541761 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | ME125575 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 18625 | 05 | AL | MEDICAID | 207365460 | 05 | IN | MEDICAID |