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General NPI Number Information
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NPI Number | 1083179378
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Entity Type | Organization
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Legal Business Name | MODERN VASCULAR OF SUN CITY, LLC
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Dates
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Enumeration Date | 01/31/2019
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Last Update Date | 01/31/2019
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Provider Practice Location Address
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Address Line | 14780 W MOUNTAIN VIEW BLVD STE 120
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City | SURPRISE
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State | AZ
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Zip | 85374-7280
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Country | US
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Telephone | 602-892-0917
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Fax | 602-842-7106
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Provider Business Mailing Address
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Address Line | 26500 AGOURA RD STE 102-587
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City | CALABASAS
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State | CA
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Zip | 91302-1952
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Country | US
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Telephone | 818-880-8605
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Fax | 818-579-7916
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Authorized Official
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Title or Position | MANAGER
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Name | YURY GAMPEL
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Credential |
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Telephone | 818-880-8605
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2471V0106X
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Taxonomy Name | Vascular-Interventional Technology Radiologic Technologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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