Provider Demographics
NPI:1134615396
Name:CAROLINA VEIN CARE AND AESTHETICS, LLC
Entity type:Organization
Organization Name:CAROLINA VEIN CARE AND AESTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:864-918-1911
Mailing Address - Street 1:103 S VENTURE DR STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3571
Mailing Address - Country:US
Mailing Address - Phone:864-918-1911
Mailing Address - Fax:
Practice Address - Street 1:103 S VENTURE DR STE B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3571
Practice Address - Country:US
Practice Address - Phone:864-918-1911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA VEIN CARE AND AESTHETICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-10
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional TechnologyGroup - Multi-Specialty