Provider Demographics
NPI:1053547083
Name:COMPREHENSIVE VASCULAR DIAGNOSTICS
Entity type:Organization
Organization Name:COMPREHENSIVE VASCULAR DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-541-0207
Mailing Address - Street 1:1892 BELLAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4548
Mailing Address - Country:US
Mailing Address - Phone:904-541-0207
Mailing Address - Fax:904-264-2067
Practice Address - Street 1:1892 BELLAIR BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4548
Practice Address - Country:US
Practice Address - Phone:904-541-0207
Practice Address - Fax:904-264-2067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty