=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588896807
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VEIN CLINIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2009
-----------------------------------------------------
Last Update Date | 11/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1699 W MAIN ST SUITE E
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-2235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-352-3366
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1000
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92244-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-353-2244
-----------------------------------------------------
Fax | 760-353-2431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. SEUNG GWON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 760-353-2244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | A81046
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------