Basic Information
| Provider Information | |||||||||
| NPI: | 1245513449 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANASOTA VASCULAR CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2138 PALM HARBOR BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PALM HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346835360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274740090 | ||||||||
| FaxNumber: | 7274744783 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 N CATTLEMEN RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342326422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413783231 | ||||||||
| FaxNumber: | 7272863873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2011 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | DEES | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7274740090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 261QM2500X | L11000095663 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.