=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194093856
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PALMS WEST VEIN INSTITUTE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2011
-----------------------------------------------------
Last Update Date | 04/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13005 SOUTHERN BLVD SUITE 221
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-9206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-907-8999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 486
-----------------------------------------------------
City | JUPITER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33468-0486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
Fax | 561-748-1523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT, JUPITER PROF DEVELOPMENT
-----------------------------------------------------
Name | KAREN BARLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-748-2889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | ME48674
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------