Healthcare Provider Details

I. General information

NPI: 1558450312
Provider Name (Legal Business Name): LASER AND VARICOSE VEIN TREATMENT CENTER OF STATEN ISLAND LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SEAVIEW AVE STE 240
STATEN ISLAND NY
10305-3403
US

IV. Provider business mailing address

500 SEAVIEW AVE STE 240
STATEN ISLAND NY
10305-3403
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-1777
  • Fax: 718-667-4380
Mailing address:
  • Phone: 718-667-1777
  • Fax: 718-667-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number119772
License Number StateNY

VIII. Authorized Official

Name: KIMBERLY CHEMO
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 732-387-2747