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General NPI Number Information
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NPI Number | 1972006351
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Entity Type | Organization
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Legal Business Name | MINIMALLY INVASIVE VASCULAR, INC
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 08/21/2023
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Provider Practice Location Address
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Address Line | 2720 US HIGHWAY 1 S STE C
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6301
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Country | US
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Telephone | 904-444-0474
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Fax |
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Provider Business Mailing Address
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Address Line | 2720 US HIGHWAY 1 S STE C
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6301
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KOK L CHONG
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Credential | MD
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Telephone | 904-320-0680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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