MEDICARE: PRECISION VASCULAR, 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	261QM2500X	Medical Specialty Clinic/Center	L7349	TX

General Provider Information

NPI Number	:	1518191394
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRECISION VASCULAR, LLC

Provider Business Mailing Address
First Line	:	PO BOX 20465
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77225-0465
Country	:	US
Telephone Number	:	877-695-3448
Fax Number	:

Provider Business Practice Location Address
First Line	:	5255 JASON ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77096-1320
Country	:	US
Telephone Number	:	877-695-3448
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. CORNELIUS DAVIS III
Credential	:	M.D.
Telephone Number	:	877-695-3448

Provider Enumeration Date	:	05/08/2009
Last Update Date	:	05/08/2009

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