Healthcare Provider Details

I. General information

NPI: 1174529739
Provider Name (Legal Business Name): MISSOURI VEIN CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 SOUTHRIDGE DR STE B
JEFFERSON CITY MO
65109-4005
US

IV. Provider business mailing address

1620 SOUTHRIDGE DR STE B
JEFFERSON CITY MO
65109-4005
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-2780
  • Fax: 573-632-2784
Mailing address:
  • Phone: 573-632-2780
  • Fax: 573-632-2784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SOPHEA THERESA MOSBY
Title or Position: EXECUTIVE ADMINISTRATIVE ASSISTANT
Credential: CPHT
Phone: 573-632-2780