1578694238 NPI number — DERMATOLOGY CENTER OF CANYON COUNTY

Table of content: (NPI 1578694238)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578694238 NPI number — DERMATOLOGY CENTER OF CANYON COUNTY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOLOGY CENTER OF CANYON COUNTY
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:
DERMATOLOGY & LASER CENTER OF CANYON COUNTY
Provider Other Organization Name Type Code:
5
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:
1578694238
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
318 2ND ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83651-3765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-467-3006
Provider Business Mailing Address Fax Number:
208-467-1155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
318 2ND ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAMPA
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83651-3765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-467-3006
Provider Business Practice Location Address Fax Number:
208-467-1155
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
POWELL
Authorized Official First Name:
GAVIN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-467-3006

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  M7519 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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