Healthcare Provider Details

I. General information

NPI: 1417208521
Provider Name (Legal Business Name): LAS OLAS DE SEQUOIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6766 W SUNRISE BLVD SUITE 100
PLANTATION FL
33313-6072
US

IV. Provider business mailing address

3 W HAWTHORN PKWY SUITE 410
VERNON HILLS IL
60061-1446
US

V. Phone/Fax

Practice location:
  • Phone: 847-388-2001
  • Fax: 847-388-2020
Mailing address:
  • Phone: 847-388-2001
  • Fax: 847-388-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES HILGER
Title or Position: CHIEF ACCOUNTING OFFICER
Credential:
Phone: 253-280-9501