Healthcare Provider Details

I. General information

NPI: 1255603247
Provider Name (Legal Business Name): GRAND VEIN SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4952 W IRVING PARK RD STE 300
CHICAGO IL
60641-2693
US

IV. Provider business mailing address

4952 W IRVING PARK RD STE 300
CHICAGO IL
60641-2693
US

V. Phone/Fax

Practice location:
  • Phone: 773-942-6141
  • Fax: 866-707-2267
Mailing address:
  • Phone: 773-942-6141
  • Fax: 866-707-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number036-116087
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-116087
License Number StateIL

VIII. Authorized Official

Name: JAVIER FLORES
Title or Position: OWNER
Credential:
Phone: 773-942-6141