1255513628 NPI number — ZENLO DERMATOLOGY, INC.

Table of content: (NPI 1255513628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255513628 NPI number — ZENLO DERMATOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ZENLO DERMATOLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1255513628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10120 W BROAD ST
Provider Second Line Business Mailing Address:
SUITE R
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23060-6709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-934-0060
Provider Business Mailing Address Fax Number:
804-934-0024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10120 W BROAD ST
Provider Second Line Business Practice Location Address:
SUITE R
Provider Business Practice Location Address City Name:
GLEN ALLEN
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23060-6709
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-934-0060
Provider Business Practice Location Address Fax Number:
804-934-0024
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LOVE
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
ROYAL
Authorized Official Title or Position:
PRESIDEDNT
Authorized Official Telephone Number:
804-934-0060

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  0101051656 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 183408 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: DD7147 . This is a "MEDICARE/ RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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