Provider Demographics
NPI:1063959310
Name:VASCULAR INTERVENTION SPECIALISTS INC
Entity type:Organization
Organization Name:VASCULAR INTERVENTION SPECIALISTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-880-7442
Mailing Address - Street 1:19231 VICTORY BLVD STE 155
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6329
Mailing Address - Country:US
Mailing Address - Phone:818-949-2630
Mailing Address - Fax:818-561-3746
Practice Address - Street 1:19231 VICTORY BLVD STE 155
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-949-2630
Practice Address - Fax:818-561-3746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-25
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1613213E00000X
213E00000X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty