1306369996 NPI number — CLEAR SKY DERMATOLOGY LLC

Table of content: (NPI 1306369996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306369996 NPI number — CLEAR SKY DERMATOLOGY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR SKY DERMATOLOGY LLC
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:
1306369996
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17620 W COLUMBINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SURPRISE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85388-5623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-853-3762
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 N 140TH AVE STE 103
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GOODYEAR
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85395-2437
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-219-4777
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SVANCARA
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
623-853-3762

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  006549 , 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: 006549 . This is a "MEDICAL LICENSE NUMBER" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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