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General NPI Number Information
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NPI Number | 1902087281
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Entity Type | Organization
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Legal Business Name | DESTIN VEIN CENTER LLC
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Dates
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Enumeration Date | 11/15/2007
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Last Update Date | 04/24/2017
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Provider Practice Location Address
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Address Line | 4485 FURLING LN
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City | DESTIN
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State | FL
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Zip | 32541-5331
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Country | US
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Telephone | 850-654-5222
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Fax | 850-637-8020
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Provider Business Mailing Address
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Address Line | 4485 FURLING LN
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City | DESTIN
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State | FL
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Zip | 32541-5331
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Country | US
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Telephone | 850-654-5222
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Fax | 850-637-8020
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Authorized Official
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Title or Position | OWNER
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Name | DR. RICHARD J GRISOLI
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Credential | MD
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Telephone | 850-654-5222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME92186
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License Number State | FL
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