Healthcare Provider Details

I. General information

NPI: 1770024721
Provider Name (Legal Business Name): CROWN POINT VEIN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 WAINWRIGHT DR
NORTHBROOK IL
60062-1900
US

IV. Provider business mailing address

333 W 89TH AVE W2
MERRILLVILLE IN
46410-7073
US

V. Phone/Fax

Practice location:
  • Phone: 847-257-1244
  • Fax: 224-246-8042
Mailing address:
  • Phone: 219-769-8346
  • Fax: 224-246-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MELVONNE JONES
Title or Position: MANAGER
Credential:
Phone: 847-257-1244