Healthcare Provider Details

I. General information

NPI: 1124050737
Provider Name (Legal Business Name): VILLAGE VEIN CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 LA GRANDE BLVD SUITE B
LADY LAKE FL
32159
US

IV. Provider business mailing address

1576 BELLA CRUZ DRIVE SUITE 332
LADY LAKE FL
32159
US

V. Phone/Fax

Practice location:
  • Phone: 352-350-2640
  • Fax: 352-350-2641
Mailing address:
  • Phone: 352-350-2640
  • Fax: 352-350-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME55201
License Number StateFL

VIII. Authorized Official

Name: DR. JENNY KAZUE YOSHIDA
Title or Position: PRESIDENT
Credential: MD
Phone: 352-350-2640