Organization
VEIN CLINIC PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES RUSSELL HEAGLE MD (PRESIDENT OWNER)
(952) 934-3296
Entity
Organization
Contact information
Practice address
470 W 78TH ST, STE 250, CHANHASSEN, MN 55317
(952) 934-3296
(952) 906-1737
Mailing address
PO BOX 84, WACONIA, MN 55387
(952) 934-3296
(952) 906-1737
Taxonomy
Speciality
Code
Description
License number
State
261QM2500X
Medical Specialty Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
40432VE
BLUE CROSS
MN
Enumeration date
12/15/2006
Last updated
08/22/2020
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