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General NPI Number Information
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NPI Number | 1033588017
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Entity Type | Organization
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Legal Business Name | ACCESS LASER & VEIN CLINIC, INC.
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Dates
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Enumeration Date | 09/19/2015
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Last Update Date | 09/19/2015
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Provider Practice Location Address
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Address Line | 333 SUNSET AVE STE 140
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City | SUISUN CITY
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State | CA
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Zip | 94585-2054
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Country | US
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Telephone | 707-334-1704
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Fax |
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Provider Business Mailing Address
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Address Line | 333 SUNSET AVE STE 140
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City | SUISUN CITY
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State | CA
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Zip | 94585-2054
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Country | US
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Telephone | 707-334-1704
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | JENNIFER ICASIANO
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Credential | BS, RVS
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Telephone | 707-334-1704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 112626
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License Number State | CA
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