Healthcare Provider Details

I. General information

NPI: 1477972933
Provider Name (Legal Business Name): LEGACY VEIN CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2014
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 N STATE OF FRANKLIN RD STE 103
JOHNSON CITY TN
37604-6063
US

IV. Provider business mailing address

310 N STATE OF FRANKLIN RD STE 103
JOHNSON CITY TN
37604-6063
US

V. Phone/Fax

Practice location:
  • Phone: 423-328-0163
  • Fax: 423-491-8109
Mailing address:
  • Phone: 423-328-0163
  • Fax: 423-491-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: GINGER REECE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 423-956-2682