Provider Demographics
NPI:1104959758
Name:INTERMOUNTAIN VEIN CENTER
Entity type:Organization
Organization Name:INTERMOUNTAIN VEIN CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:L.
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:801-225-6246
Mailing Address - Street 1:283 E 930 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-5001
Mailing Address - Country:US
Mailing Address - Phone:801-225-6246
Mailing Address - Fax:801-225-1525
Practice Address - Street 1:1055 N 300 W
Practice Address - Street 2:#308
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3344
Practice Address - Country:US
Practice Address - Phone:801-379-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty