Provider Demographics
NPI:1720391527
Name:PREMIER VEIN CARE
Entity type:Organization
Organization Name:PREMIER VEIN CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-378-8514
Mailing Address - Street 1:3268 WATERSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89044-1867
Mailing Address - Country:US
Mailing Address - Phone:815-378-8514
Mailing Address - Fax:805-540-3344
Practice Address - Street 1:3268 WATERSTONE AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-1867
Practice Address - Country:US
Practice Address - Phone:815-378-8514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ64552YOtherBLUE SHIELD PROVIDER NUMBER
CADQ8118Medicare PIN
CAZZZ64552YOtherBLUE SHIELD PROVIDER NUMBER