Healthcare Provider Details

I. General information

NPI: 1609346303
Provider Name (Legal Business Name): SUPERIOR VEIN CARE, PLLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3277 E LOUISE DR STE 360
MERIDIAN ID
83642-9359
US

IV. Provider business mailing address

3875 E OVERLAND RD STE 2D
MERIDIAN ID
83642-9005
US

V. Phone/Fax

Practice location:
  • Phone: 208-600-1550
  • Fax: 208-600-1551
Mailing address:
  • Phone: 208-484-2431
  • Fax: 866-335-0887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AZUL COHLMIA
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 208-600-1550