MEDICARE: MISSOURI VEIN CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	202K00000X	Phlebology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174529739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSOURI VEIN CARE, LLC

Provider Business Mailing Address
First Line	:	1620 SOUTHRIDGE DR STE B
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-4005
Country	:	US
Telephone Number	:	573-632-2780
Fax Number	:	573-632-2784

Provider Business Practice Location Address
First Line	:	1620 SOUTHRIDGE DR STE B
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-4005
Country	:	US
Telephone Number	:	573-632-2780
Fax Number	:	573-632-2784

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	AMBER THOMPSON
Credential	:
Telephone Number	:	573-632-2780

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	09/12/2018

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Directions to “MISSOURI VEIN CARE, LLC ” Practice Location

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