Healthcare Provider Details

I. General information

NPI: 1669534608
Provider Name (Legal Business Name): VEIN CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 W 78TH ST STE 250
CHANHASSEN MN
55317
US

IV. Provider business mailing address

PO BOX 84
WACONIA MN
55387
US

V. Phone/Fax

Practice location:
  • Phone: 952-934-3296
  • Fax: 952-906-1737
Mailing address:
  • Phone: 952-934-3296
  • Fax: 952-906-1737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHARLES RUSSELL HEAGLE
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 952-934-3296