Healthcare Provider Details

I. General information

NPI: 1063959310
Provider Name (Legal Business Name): VASCULAR INTERVENTION SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19231 VICTORY BLVD STE 155
RESEDA CA
91335
US

IV. Provider business mailing address

19231 VICTORY BLVD STE 155
RESEDA CA
91335-6329
US

V. Phone/Fax

Practice location:
  • Phone: 818-949-2630
  • Fax: 818-561-3746
Mailing address:
  • Phone: 818-949-2630
  • Fax: 818-561-3746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1613
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: JACK MORGAN
Title or Position: PRESIDENT
Credential: DPM
Phone: 310-880-7442