1699120048 NPI number — PALO DURO DERMATOLOGY, PLLC

Table of content: (NPI 1699120048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699120048 NPI number — PALO DURO DERMATOLOGY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALO DURO DERMATOLOGY, 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:
1699120048
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1638
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANYON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79015-1638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-488-2176
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2005 N 2ND AVE STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANYON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79015-2545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-553-0185
Provider Business Practice Location Address Fax Number:
806-853-6630
Provider Enumeration Date:
05/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
806-553-0185

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)

  • Identifier: 45D2117683 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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