Organization
GENESIS AESTHETIC FACE AND VEIN SPECIALISTS, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEITH CAMERON NICHOLS MD (PRESIDENT)
(757) 686-9747
Entity
Organization
Contact information
Practice address
1500 BREEZEPORT WAY, SUITE 100, SUFFOLK, VA 23435-3727
(757) 686-9747
Mailing address
1500 BREEZEPORT WAY, SUITE 100, SUFFOLK, VA 23435-3727
(757) 686-9747
Taxonomy
Speciality
Code
Description
License number
State
2086S0129X
Vascular Surgery Physician
Primary
0101040623
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
P00208779
RAILROAD MEDICARE
VA
Enumeration date
09/27/2007
Last updated
07/16/2008
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