Provider Demographics
NPI:1124050737
Name:VILLAGE VEIN CLINIC INC
Entity type:Organization
Organization Name:VILLAGE VEIN CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:KAZUE
Authorized Official - Last Name:YOSHIDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-350-2640
Mailing Address - Street 1:1576 BELLA CRUZ DRIVE
Mailing Address - Street 2:SUITE 332
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159
Mailing Address - Country:US
Mailing Address - Phone:352-350-2640
Mailing Address - Fax:352-350-2641
Practice Address - Street 1:314 LA GRANDE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-350-2640
Practice Address - Fax:352-350-2641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55201207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty