Healthcare Provider Details

I. General information

NPI: 1093571911
Provider Name (Legal Business Name): VASCULAR & VEIN CLINICS OF NORTHEASTERN PENNSYLVANIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 N KEYSER AVE
SCRANTON PA
18508-1250
US

IV. Provider business mailing address

72 VISTA RD
BERWICK PA
18603-5613
US

V. Phone/Fax

Practice location:
  • Phone: 570-231-4480
  • Fax: 570-231-4849
Mailing address:
  • Phone: 570-490-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LUIS L NADAL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 570-490-4017