Provider Demographics
NPI:1154519007
Name:CALIFORNIA VEIN & LASER CENTER MEDICAL CLINIC INC.
Entity type:Organization
Organization Name:CALIFORNIA VEIN & LASER CENTER MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:R
Authorized Official - Last Name:MONTAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-438-2800
Mailing Address - Street 1:7335 N 1ST ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2968
Mailing Address - Country:US
Mailing Address - Phone:559-438-2800
Mailing Address - Fax:559-438-8163
Practice Address - Street 1:7335 N 1ST ST STE 103
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2968
Practice Address - Country:US
Practice Address - Phone:559-438-2800
Practice Address - Fax:559-438-8163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-04
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG27007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1649281395Medicare PIN