Healthcare Provider Details

I. General information

NPI: 1255648523
Provider Name (Legal Business Name): SHEEN VEIN INSTITUTE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11144 TESSON FERRY RD SUITE 100
SAINT LOUIS MO
63123-6965
US

IV. Provider business mailing address

11144 TESSON FERRY RD SUITE 100
SAINT LOUIS MO
63123-6965
US

V. Phone/Fax

Practice location:
  • Phone: 314-842-1441
  • Fax: 314-842-1402
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number108604
License Number StateMO

VIII. Authorized Official

Name: DR. VIDAL T SHEEN
Title or Position: PRESIDENT
Credential: MD
Phone: 314-842-1441