Healthcare Provider Details

I. General information

NPI: 1144569757
Provider Name (Legal Business Name): VEIN CARE PAVILION OF THE SOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 07/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W178N9912 RIVERCREST DR SUITE 102
GERMANTOWN WI
53022-4645
US

IV. Provider business mailing address

W178N9912 RIVERCREST DR SUITE 102
GERMANTOWN WI
53022-4645
US

V. Phone/Fax

Practice location:
  • Phone: 262-672-6900
  • Fax:
Mailing address:
  • Phone: 262-672-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number44670-20
License Number StateWI

VIII. Authorized Official

Name: LORI DAVIS
Title or Position: MANAGING MEMBER
Credential:
Phone: 706-951-1998