Basic Information
Provider Information
NPI: 1912276999
EntityType: 2
ReplacementNPI:  
OrganizationName: DECATUR VEIN CLINIC COLORADO, PC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: COLORADO VEIN CLINIC PC
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 7600 PARK MEADOWS DR
Address2: SUITE 200
City: LONETREE
State: CO
PostalCode: 801242560
CountryCode: US
TelephoneNumber: 3037995199
FaxNumber: 3037996634
Practice Location
Address1: 7600 PARK MEADOWS DR
Address2: SUITE 200
City: LONETREE
State: CO
PostalCode: 801242560
CountryCode: US
TelephoneNumber: 3037995199
FaxNumber: 3037996634
Other Information
ProviderEnumerationDate: 12/21/2011
LastUpdateDate: 03/24/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: VINCENT
AuthorizedOfficialFirstName: SCOTT
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 9702637348
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
202K00000X COY193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansPhlebology 

No ID Information.


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