1124386966 NPI number — SOUTHWEST SKIN LABORATORY PLLC

Table of content: (NPI 1124386966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124386966 NPI number — SOUTHWEST SKIN LABORATORY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST SKIN LABORATORY PLLC
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:
1124386966
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1688 E BOSTON ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85295-6222
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-855-0085
Provider Business Mailing Address Fax Number:
480-855-0086

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1684 E BOSTON ST
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85295-6219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-855-0085
Provider Business Practice Location Address Fax Number:
480-855-0086
Provider Enumeration Date:
04/30/2012

Additional Information

Authorized Official

Authorized Official Last Name:
WOODS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
TRAVIS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
480-855-0085

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  03D2046062 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 757609 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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