1619492378 NPI number — FIFE DERMATOLOGY, PC 1

Table of content: (NPI 1619492378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619492378 NPI number — FIFE DERMATOLOGY, PC 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIFE DERMATOLOGY, PC 1
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:
SURGICAL DERMATOLOGY AND LASER CENTER
Provider Other Organization Name Type Code:
3
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:
1619492378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10080 WEST ALTA DRIVE
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89145-8651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-255-6647
Provider Business Mailing Address Fax Number:
702-933-1444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10080 WEST ALTA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89145-8651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-255-6647
Provider Business Practice Location Address Fax Number:
702-933-1444
Provider Enumeration Date:
08/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
FIFE
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
702-255-6647

Provider Taxonomy Codes

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

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





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