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General NPI Number Information
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NPI Number | 1003216649
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Entity Type | Organization
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Legal Business Name | TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, LLC
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Dates
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Enumeration Date | 09/02/2014
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Last Update Date | 09/02/2014
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Provider Practice Location Address
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Address Line | 1106 ALSTON AVE STE 200
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City | FORT WORTH
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State | TX
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Zip | 76104-4644
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Country | US
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Telephone | 817-698-8346
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Fax | 817-698-9933
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Provider Business Mailing Address
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Address Line | 1106 ALSTON AVE STE 200
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City | FORT WORTH
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State | TX
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Zip | 76104-4644
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Country | US
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Telephone | 817-698-8346
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Fax | 817-698-9933
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Authorized Official
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Title or Position | CEO
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Name | MR. COREY T HOLTMAN
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Credential |
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Telephone | 817-698-8346
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number | 801678647
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License Number State | TX
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