| Organization Name: | TEXAS VARICOSE VEIN CLINIC OF FORT WORTH, LLC |
| NPI Number: | 1003216649 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | COREY T HOLTMAN (CEO) |
| Mailing Address: | 1106 Alston Ave Ste 200 Fort Worth |
| State: | TX US |
| Postal Code: | 761044644 |
| Phone Number: | 8176988346 |
| Fax Number: | 8176989933 |
| NPI Enumeration Date: | 09/02/2014 |
| NPI Last Update Date: | 09/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP3300X |
| License Number: | 801678647 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | TX |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Pain |
| Taxonomy Definition: | |