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General NPI Number Information
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NPI Number | 1659541043
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Entity Type | Organization
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Legal Business Name | COSMETIC VEIN CENTERS OF VIRGINIA
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Dates
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Enumeration Date | 03/03/2008
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Last Update Date | 03/07/2008
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Provider Practice Location Address
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Address Line | 1901 S MAIN ST SUITE 2
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City | BLACKSBURG
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State | VA
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Zip | 24060-6600
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Country | US
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Telephone | 540-552-8346
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Fax | 540-951-8346
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Provider Business Mailing Address
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Address Line | 1901 S MAIN ST SUITE 2
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City | BLACKSBURG
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State | VA
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Zip | 24060-6600
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Country | US
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Telephone | 540-552-8346
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Fax | 540-951-8346
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Authorized Official
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Title or Position | OWNER
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Name | DAVID T MACMILLAN
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Credential | M.D
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Telephone | 540-552-8346
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202K00000X
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Taxonomy Name | Phlebology Physician
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License Number | 0101051292
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License Number State | VA
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