Healthcare Provider Details

I. General information

NPI: 1124206073
Provider Name (Legal Business Name): BIG COUNTRY VEIN RELIEF LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2008
Last Update Date: 02/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 S PARK DR
BROWNWOOD TX
76801-5917
US

IV. Provider business mailing address

4716 S 14TH ST
ABILENE TX
79605-4733
US

V. Phone/Fax

Practice location:
  • Phone: 325-643-3300
  • Fax: 325-641-8714
Mailing address:
  • Phone: 325-795-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State

VIII. Authorized Official

Name: ARLENE N GAULDEN
Title or Position: BOM
Credential:
Phone: 325-647-4397