# MODERN VASCULAR OF SOUTHAVEN, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1174171441
- **Authorized official:** YURY GAMPEL (MANAGER)
- **Authorized official phone:** (818) 880-8605

## Contact information

- **Practice address:** 55 PHYSICIANS LN, SOUTHAVEN, MS 38671-9569
- **Practice address phone:** (662) 655-2136
- **Practice address fax:** (662) 996-2214
- **Mailing address:** 26500 AGOURA RD STE 201, CALABASAS, CA 91302-3556
- **Mailing address phone:** (818) 880-8605
- **Mailing address fax:** (818) 579-7916

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | NULL | Yes |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | — | Yes |
| 2471V0106X | Vascular-Interventional Technology Radiologic Technologist | — | NULL | — |
| 2471V0106X | Vascular-Interventional Technology Radiologic Technologist | — | — | — |

## Other

- **Enumeration date:** 08/29/2019
- **Last updated:** 08/29/2019