Healthcare Provider Details

I. General information

NPI: 1508363714
Provider Name (Legal Business Name): VASCULAR INTERVENTIONAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6601 RUGBY AVE STE 100
HUNTINGTON PARK CA
90255-4040
US

IV. Provider business mailing address

18375 VENTURA BLVD STE 554
TARZANA CA
91356-4218
US

V. Phone/Fax

Practice location:
  • Phone: 818-949-2631
  • Fax: 818-691-2932
Mailing address:
  • Phone: 818-259-1138
  • Fax: 818-583-1696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: VLADIMIR ZEETSER
Title or Position: AUTHORIZED OFFICIAL
Credential: DPM
Phone: 818-259-1138