Basic Information
| Provider Information | |||||||||
| NPI: | 1588156541 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR VEIN RESTORATION IL LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 1000 | ||||||||
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| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1525417618 | ||||||||
| FaxNumber: | 8152545431 | ||||||||
| Practice Location | |||||||||
| Address1: | 236 E IRVING PARK RD | ||||||||
| Address2: | |||||||||
| City: | WOOD DALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601912099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | NGUYEN | ||||||||
| AuthorizedOfficialFirstName: | KHANH | ||||||||
| AuthorizedOfficialMiddleName: | Q. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8558308346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 036139055 | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.