Basic Information
| Provider Information | |||||||||
| NPI: | 1669588455 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE VEIN AND LASER CENTER OF NORTHERN COLORADO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2008 CARIBOU DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704844757 | ||||||||
| FaxNumber: | 9704844759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1915 WILMINGTON DR | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805286299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703720534 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9704826456 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.