=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518504398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR VEIN RESTORATION IA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2019
-----------------------------------------------------
Last Update Date | 11/29/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 CEDAR CROSS RD STE A
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-830-8346
-----------------------------------------------------
Fax | 240-473-4321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7474 GREENWAY CENTER DR STE 1000
-----------------------------------------------------
City | GREENBELT
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20770-3500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-830-8346
-----------------------------------------------------
Fax | 240-473-4321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SANJIV LAKHANPAL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 855-830-8346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208G00000X
-----------------------------------------------------
Taxonomy Name | Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------