Basic Information
| Provider Information | |||||||||
| NPI: | 1215548375 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR VEIN RESTORATION TN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 100 | ||||||||
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| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Practice Location | |||||||||
| Address1: | 6005 PARK AVE STE 225B | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | KHANH | ||||||||
| AuthorizedOfficialMiddleName: | Q | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8558308346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.