MEDICARE: VEIN CENTER OF LAKE NORMAN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician		NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141KR	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1356531172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VEIN CENTER OF LAKE NORMAN PA

Provider Business Mailing Address
First Line	:	10215 HICKORYWOOD HILL AVE
Second Line	:	SUITE B
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3428
Country	:	US
Telephone Number	:	704-947-7027
Fax Number	:

Provider Business Practice Location Address
First Line	:	10215 HICKORYWOOD HILL AVE
Second Line	:	SUITE B
City	:	HUNTERSVILLE
State	:	NC
Zip	:	28078-3428
Country	:	US
Telephone Number	:	704-947-7027
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	NANCY MOORE
Credential	:
Telephone Number	:	512-342-0455

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	07/27/2007

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