Healthcare Provider Details

I. General information

NPI: 1689893224
Provider Name (Legal Business Name): VEIN TREATMENT CENTER OF PALM COAST P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 HOSPITAL DR SUITE 260
PALM COAST FL
32164-2452
US

IV. Provider business mailing address

PO BOX 279
FLAGLER BEACH FL
32136-0279
US

V. Phone/Fax

Practice location:
  • Phone: 386-586-5344
  • Fax: 386-586-5450
Mailing address:
  • Phone: 386-586-5344
  • Fax: 386-586-5450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberOS4153
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VH0002X
TaxonomyHospice and Palliative Medicine (Obstetrics & Gynecology) Physician
License NumberME39243
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS4153
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License NumberME39243
License Number StateFL

VIII. Authorized Official

Name: DR. NICKOLAS JOHN COLLUCCI
Title or Position: PRESIDENT
Credential: D.O.
Phone: 386-586-5344