=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124050737
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VILLAGE VEIN CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2006
-----------------------------------------------------
Last Update Date | 09/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 314 LA GRANDE BLVD SUITE B
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-350-2640
-----------------------------------------------------
Fax | 352-350-2641
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1576 BELLA CRUZ DRIVE SUITE 332
-----------------------------------------------------
City | LADY LAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-350-2640
-----------------------------------------------------
Fax | 352-350-2641
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JENNY KAZUE YOSHIDA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 352-350-2640
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME55201
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------