Provider Demographics
NPI:1902087281
Name:DESTIN VEIN CENTER LLC
Entity Type:Organization
Organization Name:DESTIN VEIN CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:GRISOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-654-5222
Mailing Address - Street 1:4485 FURLING LN
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-5331
Mailing Address - Country:US
Mailing Address - Phone:850-654-5222
Mailing Address - Fax:850-637-8020
Practice Address - Street 1:4485 FURLING LN
Practice Address - Street 2:
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-5331
Practice Address - Country:US
Practice Address - Phone:850-654-5222
Practice Address - Fax:850-637-8020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-15
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92186174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME92186OtherSTATE LICENSE