Healthcare Provider Details

I. General information

NPI: 1164897427
Provider Name (Legal Business Name): CENTER FOR VEIN RESTORATION AL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 ROSS CLARK CIR
DOTHAN AL
36303-3040
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR SUITE 1000
GREENBELT MD
20770-3504
US

V. Phone/Fax

Practice location:
  • Phone: 855-830-8346
  • Fax: 240-473-4321
Mailing address:
  • Phone: 855-830-8346
  • Fax: 240-965-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: LORENA THOMAS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 815-254-1761