MEDICARE: CENTER FOR VEIN RESTORATION MD 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	225X00000X	Occupational Therapist	0119005026	VA

General Provider Information

NPI Number	:	1205190626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR VEIN RESTORATION MD LLC

Provider Business Mailing Address
First Line	:	7025 GROVE RD
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22306-1428
Country	:	US
Telephone Number	:	703-785-8792
Fax Number	:

Provider Business Practice Location Address
First Line	:	7025 GROVE RD
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22306-1428
Country	:	US
Telephone Number	:	703-785-8792
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	OLGA PLEFFNER
Credential	:
Telephone Number	:	301-860-0003

Provider Enumeration Date	:	06/29/2012
Last Update Date	:	06/29/2012

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