Provider Demographics
NPI:1720388267
Name:CENTER FOR VEIN RESTORATION MI PLLC
Entity type:Organization
Organization Name:CENTER FOR VEIN RESTORATION MI PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-254-1761
Mailing Address - Street 1:7474 GREENWAY CENTER DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3500
Mailing Address - Country:US
Mailing Address - Phone:855-830-8346
Mailing Address - Fax:
Practice Address - Street 1:3810 W CENTRE AVE STE A
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4632
Practice Address - Country:US
Practice Address - Phone:301-860-0930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053733208600000X, 208G00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies