1376721167 NPI number — SOUTH END SKIN CARE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376721167 NPI number — SOUTH END SKIN CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH END SKIN CARE, 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:
6
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:
1376721167
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
321 COLUMBUS AVENUE
Provider Second Line Business Mailing Address:
SUITE 2R
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02116-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
857-362-7330
Provider Business Mailing Address Fax Number:
857-362-7332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 COLUMBUS AVENUE
Provider Second Line Business Practice Location Address:
SUITE 2R
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02116-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
857-362-7330
Provider Business Practice Location Address Fax Number:
857-362-7332
Provider Enumeration Date:
02/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
SCHANBACHER
Authorized Official First Name:
CARL
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
857-362-7330

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207NS0135X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0005608 . This is a "MEDICARE PTAN" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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