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General NPI Number Information
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NPI Number | 1992996821
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Entity Type | Organization
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Legal Business Name | VARICOSE VEIN CENTER OF ST LOUIS, INC
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Dates
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Enumeration Date | 08/06/2007
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Last Update Date | 08/06/2007
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Provider Practice Location Address
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Address Line | 12360 MANCHESTER RD STE 206
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City | SAINT LOUIS
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State | MO
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Zip | 63131-4312
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Country | US
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Telephone | 314-966-6100
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Fax | 314-966-8148
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Provider Business Mailing Address
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Address Line | 12360 MANCHESTER RD STE 206
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City | SAINT LOUIS
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State | MO
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Zip | 63131-4312
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Country | US
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Telephone | 314-966-6100
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Fax | 314-966-8148
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK F BLUMENTHAL
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Credential | MD
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Telephone | 314-966-6100
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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 | R7718
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License Number State | MO
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