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Name
First Last
Email*
Cell Phone*
Office Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Days / Hours Open
Location Sq. Footage
Number of Locations:
Number of Physicians:
Number of Procedures 2021
Laser Ablation (CPT 36478)
RF Ablation (CPT 36475)
Varithena (CPT 36465)
MOCA / ClariVein (CPT 36474)
VenaSeal (CPT Code 36482)
Foam Sclerotherapy (CPT code
Number of Procedures 2022
Laser Ablation (CPT 36478)
RF Ablation (CPT 36475)
Varithena (CPT 36465)
MOCA / ClariVein (CPT 36474)
VenaSeal (CPT Code 36482)
Foam Sclerotherapy (CPT code
Collections & Expenses
Estimated Annual Collections
Estimated Annual Expenses
Medical Specialty:
Boards:
Certifications
Hospital Affiliations:
State Licenses: