Provider Demographics
NPI:1548343098
Name:ELITE VEIN CENTER OF DESTIN LLC
Entity type:Organization
Organization Name:ELITE VEIN CENTER OF DESTIN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARCUS
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-837-4043
Mailing Address - Street 1:12671 EMERALD COAST PKWY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550-8300
Mailing Address - Country:US
Mailing Address - Phone:850-837-4043
Mailing Address - Fax:850-837-5245
Practice Address - Street 1:12671 EMERALD COAST PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550-8300
Practice Address - Country:US
Practice Address - Phone:850-837-4043
Practice Address - Fax:850-837-5245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82824261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01341WMedicare ID - Type Unspecified
G71349Medicare UPIN