Healthcare Provider Details

I. General information

NPI: 1114749439
Provider Name (Legal Business Name): CENTER FOR VEIN RESTORATION MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8316 ARLINGTON BLVD STE 515
FAIRFAX VA
22031-5216
US

IV. Provider business mailing address

7474 GREENWAY CENTER DR STE 1000
GREENBELT MD
20770-3500
US

V. Phone/Fax

Practice location:
  • Phone: 855-830-8346
  • Fax: 240-473-4321
Mailing address:
  • Phone: 815-254-1761
  • Fax: 240-473-4321

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: LORENA THOMAS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 815-254-1761