MEDICARE: PREMIER VEIN CARE

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	ZZZ64552Y	OTHER	CA	BLUE SHIELD PROVIDER NUMBER

General Provider Information

NPI Number	:	1720391527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER VEIN CARE

Provider Business Mailing Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:	805-540-3344

Provider Business Practice Location Address
First Line	:	3268 WATERSTONE AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1867
Country	:	US
Telephone Number	:	815-378-8514
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KENNETH STEVENS
Credential	:	M.D.
Telephone Number	:	815-378-8514

Provider Enumeration Date	:	07/21/2010
Last Update Date	:	05/05/2025

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Directions to “PREMIER VEIN CARE ” Practice Location

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