Healthcare Provider Details

I. General information

NPI: 1124161716
Provider Name (Legal Business Name): LASER VEIN CENTER OF FAIRBANKS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 GAFFNEY RD SUITE 300
FAIRBANKS AK
99701-4914
US

IV. Provider business mailing address

PO BOX 440
ESTER AK
99725-0440
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-8346
  • Fax: 907-451-8346
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number903255
License Number StateAK

VIII. Authorized Official

Name: DR. DONALD IVES
Title or Position: MANAGER
Credential: MD
Phone: 907-452-8346