Healthcare Provider Details

I. General information

NPI: 1124670930
Provider Name (Legal Business Name): USA VEIN CLINICS OF CHANTILLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3914 CENTREVILLE RD STE 125
CHANTILLY VA
20151-3289
US

IV. Provider business mailing address

304 WAINWRIGHT DR
NORTHBROOK IL
60062-1900
US

V. Phone/Fax

Practice location:
  • Phone: 847-593-8460
  • Fax: 224-235-4652
Mailing address:
  • Phone: 847-593-8460
  • Fax: 224-235-4652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: AMI ALMEDA
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 224-318-0118