Healthcare Provider Details

I. General information

NPI: 1588156541
Provider Name (Legal Business Name): CENTER FOR VEIN RESTORATION IL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BUTTERFIELD RD STE 1000
DOWNERS GROVE IL
60515-5476
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR STE 1000
GREENBELT MD
20770-3500
US

V. Phone/Fax

Practice location:
  • Phone: 855-830-8346
  • Fax:
Mailing address:
  • Phone: 152-541-7618
  • Fax: 815-254-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036139055
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. KHANH Q. NGUYEN
Title or Position: OWNER
Credential: DO
Phone: 855-830-8346