Healthcare Provider Details

I. General information

NPI: 1306518600
Provider Name (Legal Business Name): ELITE VEIN HARVESTERS & STAFFING L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2021
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 SHAFTSBURY DR
CORPUS CHRISTI TX
78415-4483
US

IV. Provider business mailing address

2425 SHAFTSBURY DR
CORPUS CHRISTI TX
78415-4483
US

V. Phone/Fax

Practice location:
  • Phone: 361-459-9680
  • Fax:
Mailing address:
  • Phone: 361-459-9680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. JORGE VILLARREAL
Title or Position: CEO
Credential: LSA
Phone: 361-459-9680