Basic Information
| Provider Information | |||||||||
| NPI: | 1225640717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | USA VEIN CLINICS OF UTAH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 WAINWRIGHT DR | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600621900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475938460 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Practice Location | |||||||||
| Address1: | 6028 S RIDGELINE DR | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3854325838 | ||||||||
| FaxNumber: | 2242354652 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2020 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | KATSNELSON | ||||||||
| AuthorizedOfficialFirstName: | FLORA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8475938460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 08/18/2020 | ||||||||
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.