Healthcare Provider Details

I. General information

NPI: 1619244555
Provider Name (Legal Business Name): DOUGLAS VASCULAR CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2011
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 SHIRLEY AVE
DOUGLAS GA
31533-2332
US

IV. Provider business mailing address

3001 PALM HARBOR BLVD STE A
PALM HARBOR FL
34683-1930
US

V. Phone/Fax

Practice location:
  • Phone: 727-474-0090
  • Fax:
Mailing address:
  • Phone: 727-474-0090
  • Fax: 727-474-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number11081332
License Number StateFL

VIII. Authorized Official

Name: MRS. JANET R DEES
Title or Position: MANAGING MEMBER
Credential: MANAGING MEMBER
Phone: 727-474-0090