Healthcare Provider Details

I. General information

NPI: 1407298920
Provider Name (Legal Business Name): VEIN & COSMETIC CENTER OF PRATTVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 PINNACLE PL
PRATTVILLE AL
36066-6544
US

IV. Provider business mailing address

700 MONTGOMERY HWY SUITE 210
VESTAVIA AL
35216-1866
US

V. Phone/Fax

Practice location:
  • Phone: 205-823-0151
  • Fax: 205-823-5218
Mailing address:
  • Phone: 205-823-0150
  • Fax: 205-823-5218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number280663
License Number StateAL

VIII. Authorized Official

Name: DR. JOHN R KINGSLEY
Title or Position: PRESIDENT & OWNER
Credential:
Phone: 205-823-0151